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Vol. L^yi, No. 1 One Year $2

Serology and Obstetrics, by R. T. La Vake, M.D 1

Free Plasma Service in North Dakota, by Melvin E. Koons, M.P.H 4

Short Leg Backache, by John M. Butler, M.D 10

Some Common Skin Diseases and Their Treatment, by Herbert C. Lciter, M.D 12

Book Reviews 18

Editorials:

The Medical Outlook in the New Year 19

A.M.A. House of Delegates Meeting 20

Announcements 20

Meet Our Contributors 21

News Items 22

Measuring the Community for a Hospital 24

Necrology 26

Physicians Licensed by Minnesota State Board November 9, 1945 29

Serves the Medical Profession of

Minnesota, North Dakota, South Dakota, and Montana

76th Year of Publication

octor— Judge

hilip Morris suggests you judge . . . from

the evidence of your own personal obser-

vations . . . the value of Philip Morris Ciga-
rettes to your patients with sensitive throats.

PUBLISHED STUDIES* SHOWED WHEN SMOKERS
CHANGED TO PHILIP MORRIS SUBSTANTIALLY EVERY
CASE OF THROAT IRRITATION DUE TO SMOKING
CLEARED COMPLETELY, OR DEFINITELY IMPROVED.

But naturally, no published tests, no matter
how authoritative, can be as completely con-
vincing as results you v/ill observe for yourself.

Philip Morris

PHILIP MORRIS & CO., LTD., INC.

1 19 FIFTH AVENUE, NEW YORK, N. Y.

* Laryngoscope, Feb. 1935, Vol. XLV, No. 2, 149-154-
Laryngoscope, Jan. 1937, Vol. XLV1I, No. 1, 58-60.

TO THE DOCTOR WHO SMOKES A PIPE: We suggest an unusually fine new blend -
COUNTRY Doctor Pipe Mixture. Made by the same process as used in the manufacture of
Philip Morris Cigarettes.

Publication Office, 514 Essex Building, 84 So. 10th St., Minneapolis 2, Minn.

Entered as second-class matter at the postoffice at Minneapolis under the act of March 3, 1879.
Published monthly by the Lancet Publishing Co.

Serology and Obstetrics

R. T. La Vake, M.D.

Minneapolis

THE demand for a safe transfusion approach and
an answer to the problems involved in erythro-
blastosis has led many men in the Central North-
west to attack these problems intensively. The result is
the accumulation of a large pool of antibody findings
under the supervision of Dr. R. W. Koucky, serologist
and pathologist to Abbott Hospital, Minneapolis. The
setup also provided an unusual opportunity for anyone
interested in the associated problem of pregnancy tox-
emia. This paper gives an obstetrical interpretation of
what the antibody titers seem to indicate, from the point
of view of theory and practice.

The clinical, pathological, and serologic evidence that
has increasingly converged in proof upon the fetal toxin
hypothesis of pregnancy toxemia is familiar to all of you.
It involves the work of Veit, Dienst, James Young, Mc-
Quarrie, Ottenberg, and Bartholomew and Colvin, to
name but a few investigators. The proof was never con-
clusive because it failed to identify a specific toxin in the
fetus against which, in the mother, an antitoxin could
be demonstrated that showed a functional relationship
with the fetal toxin.

Until 1936 the serologic approach had been unsatis-
factory. Then Jonsson showed that one could often pre-
dict the future group status of the fetus by the titering
of maternal antibodies. With an O group mother and
an A group husband, the rise of the a antibody above
average allowed the prediction of an A group child.
A group B prediction could be made when the b anti-
body rose above average with a group B husband.
Now, these were the cases in which toxemia had been

Presented at the meeting of the North Dakota Society of Ob-
stetrics and Gynecology, Grand Forks, November 3, 1945.

found by obstetricians since 1919, and the phenomenon
could be interpreted as a response of an antitoxin to a
toxin. Many maintained that the A and B antigens
could not be defined serologically as toxins, nor could
the a and b antibodies be defined as antitoxins. They
were by serologic definition merely simple antigens and
agglutinogens, and antibodies and agglutinins. Even if
one were serologically in error to the extent of interpret-
ing them as possible toxins and antitoxins, how could one
account for the many cases of toxemia in which no blood
group incompatibility existed between child and mother?
This had been the insistent question that led to the ex-
ploration of other fields of proof in the fetal toxin
problem. Possibly the toxin was of a nature not de-
monstrable by blood group incompatibility. This line of
thought led to the development of a maternal skin test,
which, like the Mantoux test in tuberculosis, seemed to
show that in pregnancy toxemia the mother was im-
munized to a specific toxin coming from the fetus. But
this test did not identify the toxin, and it could be used
only after the birth of the child.

Then came the discovery of the so-called Rh factor by
Landsteiner and Wiener and the work of Levine, Katzin,
and Burnham, showing the relationship of the Rh factor
to erythroblastosis fetalis, abortions, stillbirths, and
macerated fetuses. To the investigator of the toxemias
of pregnancy these discoveries took on a much wider
significance than was manifest in their obvious impor-
tance in erythroblastosis and blood transfusion. This dis-
covery of the Rh factor furnished a possible answer to
the insistent question mentioned above, and the work on
erythroblastosis furnished further evidence in regard to
the fetal toxin hypothesis by completing the circle of

The Journal Lancet

the classical and accepted toxin antitoxin mechanism.
At first the Rh factor held the field, but it soon became
apparent that the A and B antigens could bring about
erythroblastotic injury and disaster when the Rh status
of husband and wife was similar. It became apparent
that the only reason why the Rh antigen or agglutinogen
had not operated in the original setup of the blood
groups was because its specific antibody, or antitoxin
from the standpoint of disease, happened not to be in-
heritable. Had it been inheritable, our knowledge of the
blood group setup would probably have been delayed
many years, possibly until 1941.

It would seem that the mounting serologic and obstet-
rical evidence of forty years demands a reassessment of
the genetic purpose of the blood groups and a change
in definitions. It appears that the A, B, and Rh antigens
function genetically as toxins, and their corresponding
antibodies as antitoxins. These are their essential prop-
erties in the genetic setup, and thus, by the rules of logic,
these properties must appear in their adequate definition.
In nature, their properties as agglutinogens and agglu-
tinins are used as secondary weapons in the genetic toxin
antitoxin battle. Here the red cells act just as do bac-
teria under antitoxin attack. Their original definition
was conditioned by the nature of the experiments that
brought about their definition, namely, the gross mixture
of incompatible bloods, a situation which does not obtain
in nature and against which the genetic mechanism was
not set up. From the point of view of phylogenetic
ontogeny it would seem that the A and B toxins were
incorporated as inheritable long before their specific anti-
toxins were inheritable. By the same token, it would
seem that the Rh toxin was incorporated as inheritable
later than the A and B toxins, and too late for its anti-
toxin to become inheritable.

Now to get back to the Rh antigen. If this antigen
is interpreted as a toxin, why is it that we find only a
30 per cent correlation between erythroblastosis and the
manifestations of pregnancy toxemia? It may be sug-
gested that the same law holds here that obtains in snake
venom poisoning; namely, that, all things being equal,
the manifestations of toxemia in the host vary directly
with the strength and amount of the toxin and indirectly
with the strength and amount of the generated or arti-
ficially administered antitoxin. Maternal antibody titers
tend to show the functioning of this very law. Where
the anti A, B, or Rh antibody titers tend to be low we
see toxemia, but as soon as the fetus with its antibody
absorptive power is removed the antibody jumps to many
times its antepartum strength, with a rapid subsidence
of toxic symptoms and signs. It may jump, for example,
from 1-1000 antepartum to 1-100,000 five days post-
partum. The highest jumps have been found in cases
of erythroblastosis in which no toxemia was found, or
at least noticed. One such case jumped from 1-8000
antepartum to 1-8,000,000-plus postpartum. Here the
reasoned interpretation is that the antitoxin strength was
high enough to protect the mother, but so high that it
injured the fetus. This is the pattern. Only time and
hundreds of observations can sustain this law as a func-
tional generalization.

The studies of antibodies would seem to show that
the link between toxemia of pregnancy and premature
separation of the normally implanted placenta is the
basic toxin antitoxin setup. One of the interesting fea-
tures of this approach is that you can check your out-
standing cases of toxemia and premature separation for
years back if the mothers and children are available.

A most interesting and obstetrically significant finding
was that during an outstanding infection a titer might
rise from ten to twenty times its former strength and then
return to its preinfection level. This finding is significant
from the point of view of the high correlation of infec-
tion and fetal death and abortion. It also furnishes
some substantiation of the claim that so-called placental
infarcts can be presumed to have taken place during an
infection — an occurrence said to be impossible because
bacteria and the usual signs of inflammation are not
found in or around infarcts. It is probably a toxin anti-
toxin reaction involving fetal red cell agglutination at
the sites of breaks in the integrity of the placenta. This
mechanism probably accounts for the high correlation
between toxemia and placental infarction.

This seems to be one of the purposes of the agglu-
tination function. It is probable that the comparatively
few fetal red cells that gain access to the maternal cir-
culation are agglutinated, and this agglutination merely
marks the beginning of their demise and disintegration,
as with the clumping of bacteria under antitoxin attack.
The result is that the liberated toxin merely augments
the toxin already in the serum. It is the toxin that in-
jures the maternal cells. Thus we see in toxemia autop-
sies the effects of the toxins free from the obscuring
features of agglutination and hemolysis seen in trans-
fusion deaths. In transfusion deaths the agglutinative
and hemolytic features, which usually cause rapid death,
obscure the pathology caused by the toxin. We see a
closer similarity between the pathology of pregnancy
toxemia and the pathology found in delayed transfusion
deaths.

Antibody studies lead to the following practical inter-
pretations and applications: Where one finds that the

A, B, and Rh status of husband and wife is similar or
compatible, one can feel quite sure that toxemia, pre-
mature separation of the normally implanted placenta,
or erythroblastosis will not supervene and that the likeli-
hood of abortion is much reduced. Again, if blood is
needed for the mother, the blood of the husband can be
used without loss of time. Any variation from these
ideal conditions forewarns one and indicates preparation
well in advance for possible contingencies.

From the point of view of prophylaxis in toxemia and
erythroblastosis, it is well to clear up all foci of infection
and caution the mother to avoid all sources of general
infection during pregnancy.

If you are following a toxemia serologically, do not
be misled by a temporary amelioration of symptoms dur-
ing an infection. It may be due to a rise in antibody
strength. Instead, visualize the likelihood of gross in-
farction, with serious consequences when the antibody
strength drops back to preinfection level and the necros-
ing infarcts increase the strength of the toxin attack.

January, 1946

Experience corroborates the lag between acute infection
and the severe accession of toxemia. These patients
should be watched daily.

The time will probably come when a safe antitoxin
antepartum therapy can be worked out for toxemics.
The direction is obvious. However, until the fetus is
separated from the mother the danger of such an ap-
proach is also obvious. Such therapy would appear to
be as reasonable as the transfusion of blood in erythro-
blastotic babies, in postpartum eclampsias, and in miti-
gating the deleterious effects of the toxin in postpartum
recovery. In order to get an effectively high antitoxin
titer, one needs to have at hand a woman who is recov-
ering from a recent similar toxemia or an erythroblastotic
experience, has reached the fifth day postpartum, when
the titer is generally at its highest point, and whose blood
is otherwise compatible. A large order, but it will be
worked out.

From the point of view of transfusion, if a woman
is Rh negative, beware the possibility of isoimmunization
in even the first transfusion if she is pregnant or has ever
been pregnant or transfused. More important still is the
responsibility resting upon all to use Rh similar blood in
the transfusion of all women, to prevent the possible
consequences of isoimmunization. It has been estimated
that transfusion is ten times more likely to isoimmunize
a woman than is a pregnancy. Failure to follow this in-
junction may at any time before menopause destroy a
woman’s ability to bear viable children. The frequency
of transfusion in the interests of therapy is increasing
rapidly, and the end is not yet in sight.

Now as regards erythroblastosis, which is so rare, ow-
ing to nature’s placental and other safeguards, that few
make it a point to determine the A, B, and Rh status of
the husband and wife as routinely as the Wassermann
status. Obviously all can be determined with one draw-
ing of blood.

For the past four years at Abbott Hospital, Minne-
apolis, the blood of every newborn has been examined
for evidences of erythroblastosis by Dr. Koucky and his
staff, not only to direct immediate treatment, but also
to direct examination of the blood status of husband and
wife. Until a definite fetal disaster occurs this seems
to be the best approach for practical purposes. The tests
are simple and can be carried out in any physician’s
office. Any infant is viewed with suspicion if the hemo-
globin is 100 or under or the erythroblasts number over
10 per 100 leucocytes counted. After one fetal disaster,
however, if in the next pregnancy the antibody at fault
appears or the rising titer of the antibody points to the
presence of another offending fetus — it must always be
remembered that this fetus might be consonant with
the mother — the most successful attack appears to be
the separation of the fetus by cesarean as soon as it
has reached the age of viability, with all preparations
made for multiple transfusions as indicated. If, however,
the Rh antibody is what is known as a blocked antibody,
this approach is useless. In such a case the baby either
dies before reaching the age of viability or will be born
diseased beyond the aid of multiple transfusions. Dr.

Koucky states that in his serologic experience he has
seen only one possible exception to this eventuality in
about forty cases.

This brings up a problem that is troubling many men.
We know what the ravages of pregnancy toxemia do
to disable and shorten the lives of women. Why should
we blithely believe that the horrible pathology exhibited
by some erythroblastotic infants can be cleared up with-
out leaving results that may cruelly handicap the child?
There are many blood dyscrasias that may well stem
from this very injury in fetal life. Our responsibilities
are clear when the baby is born erythroblastotic. It is
not so clear, however, that we should increase the danger
to the mother by the use of cesarean section, in the face
of the uncertain outcome for the child. In an attempt
to solve this problem by analogy, experiments are being
set up to determine the consequences to young rattle-
snakes of giving them rattlesnake antivenom. These ex-
periments will be watched with interest, for theoretically,
if the hypothesis of the toxin antitoxin setup in human
beings is correct, if it were biologically possible to attach
a rattlesnake of low-grade virulence to its host as a fetus
is attached to its mother, one could probably protect the
host and injure or kill the snake in situ by the adequate
use of antivenom in the host.

Conclusions

Genetics decrees that the relationship between fetus
and mother is a toxin antitoxin relationship if the fetus
contains toxic antigens not possessed by the mother.
Three of the now known and lettered antigens, the A,
B, and Rh antigens, are, by definition, toxins when func-
tioning under these conditions.

Agglutination and further hemolysis of the fetal red
cells, if they can gain access to the maternal circulation,
are but steps in the further liberation of toxins, which
augment the strength of the toxins already in the serum.

The symptoms, signs, and pathology of the toxemias
are caused by one or more of these three antigens. There
may be other antigens, yet unknown.

In erythroblastosis fetalis we are witnessing the de-
structive action of the corresponding specific antitoxins
on the cells from which the toxins arose.

One of the functions of the placenta is to act as a first
line of defense in the genetic toxin antitoxin battle.
Owing to the anatomic structure of the placenta this
line of defense is at times broken down. Nature attempts
to seal these leaks by the formation of so-called infarcts.

An understanding of the toxin antitoxin relationship
suggests the proper direction of therapy in toxemia,
erythroblastosis, and delayed transfusion pathology.

If a woman is Rh negative, beware the possibility of
isoimmunization in even the first transfusion, if she is
pregnant or has ever been pregnant. A great responsi-
bility rests upon all to use Rh similar blood in the trans-
fusion of all females, to prevent the possible conse-
quences of isoimmunization. Transfusion is ten times
more likely to isoimmunize a woman than is a pregnancy.
Failure to follow this injunction may at any time before
menopause destroy a woman’s ability to bear viable
children.

The Journal Lancet

Free Plasma Service in North Dakota

Melvin E. Koons, M.S., M.P.H.

Grand Forks, North Dakota

FREE blood plasma for civilian use is a reality in
North Dakota. The State Health Department has
conclusively shown during the past year that such
a program is feasible on a state-wide basis and can be
operated economically.

Recently a plan was worked out for the participation
of the American Red Cross in civilian blood donor pro-
grams for civilian use throughout the nation. Details
of the new Red Cross service were given in a report in
the July 7, 1945, issue of the Journal of the American
Medical Association. Because of the tremendous interest
this report may arouse for the future establishment of
civilian blood plasma programs by state agencies, a de-
scription of the experiences encountered in setting up
the North Dakota program may be of value. The pur-
pose of this paper, therefore, is to outline the establish-
ment and operation of a state-wide blood plasma pro-
gram which has proved to be a practical venture for a
state health department.

There is no question of the value of blood plasma in
the civilian practice of medicine. Many articles have
appeared in the literature during the past several years
to substantiate the fact that blood plasma and its deriva-
tives are responsible for the saving of many lives. How-
ever, health authorities have debated whether or not such
a program should or could be handled by health depart-
ments or whether it should be left to hospitals or some
other medical agency. In a paper presented before the
health officers section of the American Public Health
Association in October 1944, Dr. J. B. Alsever 1 re-
marked: "It may be desirable for public health labora-
tories to undertake serum center projects. This may be
accomplished by interesting and aiding large hospitals to
expand their blood plasma banks to include such a serv-
ice, or by establishing a plasma or serum service in a
public health laboratory. It is also important that the
reserves of pooled normal adult plasma developed to
meet the needs of those injured in disasters be main-
tained after the war, so that injured civilians can receive
the same excellent and prompt care that has been pos-
sible in most of the serious accidents occurring during
the past year. This would seem to be the logical interest
of health officers who should promote, properly control,
and further such a program.”

The development and maintenance of plasma reserves
through a free state-wide distribution program for the
treatment of the sick and injured is a real challenge to
those charged with guarding the health of the state and
the nation. North Dakota’s program 2 started in March
1944 with an appropriation of funds by the state legis-
lature for the purpose of establishing a free blood plasma
service by the State Department of Health in coopera-
tion with the University of North Dakota. The pro-
gram embraces the procurement of blood from volunteer

donors, its processing to the desired state, and free dis-
tribution of the final product.

Type of Blood Plasma

The first problem to be decided was in what form
plasma should be prepared — liquid, frozen, or dried. In
processing blood full consideration must be given the
characteristics of the end product. Ideally, the compo-
sition of the stored plasma should be as much like that
of the freshly prepared product as possible. In thinking
of a state-wide service, factors to be considered are the
degree of stabilization desired, the storage facilities avail-
able, and the amount of handling or transportation an-
ticipated. The separated plasma can be stored in the
liquid state, can be frozen, or can be dried from the
frozen state.

Liquid plasma is the most economical to prepare; how-
ever, it does have certain disadvantages. In the liquid
state plasma retains the colloidal properties necessary for
the treatment of shock, but the more labile components,
the prothrombin and fibrinogen concerned with blood
coagulation, the complement and antibodies concerned
with immunity, deteriorate with time. The possibility of
contamination and failure to detect it clearly indicated
the need for a more stable product which could be used
safely under any and all rural conditions, since North
Dakota is primarily a rural state. For an economical
civilian program, therefore, liquid plasma has distinct
limitations and was considered unsatisfactory for our
purposes.

In the frozen state, the labile components of plasma
are better preserved. Here the limitation is the incon-
venience of storage and transportation for immediate
emergency use. In order to transport frozen plasma
from the central processing laboratory to points in the
state, dry ice would have to be used and every precau-
tion taken to insure that the product remained frozen
at all times. Then, too, the depots would have to have
adequate low temperature storage, which would limit
the range of distribution. Also, frozen plasma has to be
placed in a 37°C. water bath for at least thirty minutes
before administration. For these reasons, frozen plasma
was not considered a practical product for a state-wide
program.

Dried plasma seemed to be the product of choice. In
the dried state most of the labile components of plasma
are preserved. This product is easily restored to the
liquid state by the addition of the proper diluent, and
the solubility time is less than three minutes, with a
small amount of shaking. The dried plasma can survive
a wider range of temperature variation without denatur-
ing or precipitating protein than any of the other types
of plasma. It can be more efficiently transported and
does not require any special place for storage. The only

January, 1946

disadvantage of dried plasma is that restoration to the
liquid state requires additional manipulation.

Processing Laboratory

The next important problem confronted in establishing
the program was the choice of the type of equipment
and laboratory facilities necessary for the production of
dried plasma. A completely new laboratory was finally
set up in three rooms located in the same building with
the public health laboratory at the University of North
Dakota. The standard apparatus* used for dehydration
is that developed by Dr. Max Strumia and Dr. John S.
McGraw 3 of the Bryn Mawr (Pennsylvania) Hospital.
This apparatus is capable of shell freezing and dehydrat-
ing over five thousand units of plasma per year.

The laboratory itself has one room for the refrigera-
tion of whole blood, centrifuging of blood samples, and
desiccation of the plasma; a second room which serves
as a preparation and washing room; and a third room
which is a sterility room for storing frozen plasma and
pooling and dispensing plasma.

A closed system is used throughout the technical pro-
cedure and most of the supplies are reusable. Plasma is
prepared in accordance with the requirements of the
National Institute of Health and as outlined in the
Office of Civilian Defense Manual.''

A small staff is adequate to operate a program such
as we have in North Dakota. The entire program is
administered by the Director of Laboratories of the
State Health Department, who schedules and manages
the donor clinics and controls the distribution of the
final product. A trained bacteriologist is in direct charge
of the plasma laboratory and is responsible for all tech-
nical procedures. One nontechnical assistant in the lab-
oratory and a dishwasher complete the staff. The director
and the bacteriologist in charge of the processing labora-
tory set up all clinics and assist local personnel in their
operation. The local people, including the physician, fur-
nish all other help on a volunteer basis.

Blood Donor Clinics

Blood is procured from volunteer donors only, with-
out the payment of a fee. Prior to the institution of
the program, no public donor clinics were ever held in
North Dakota. The people naturally had heard and
read of National Red Cross programs for the Armed
Forces, but the Red Cross had not been in any part of
the state. This meant that we should in no way inter-
fere with the Red Cross program.

Before clinics were held an educational program had
to be set up, stressing the fact that there was a need for
a state-wide civilian plasma program and that all blood
collected would be retained and used within the state.
This was accomplished on a more or less local basis in
the communities where clinics were to be held.

During the first year many problems presented them-
selves, and it is the belief of the writer that each state
attempting such a program will have its own individual
problems to consider. In North Dakota we found that
such things as weather and time of the year were im-
portant factors to be considered. Difficulty was encoun-

•Manufactured by the Precision Scientific Co., Chicago, and dis-
tributed through the A. S. Aloe Company, St. Louis.

tered in trying to get people out to clinics during the
severely cold months, and during the planting and har-
vest seasons communities were not responsive to holding
clinics because people could not afford to lose time from
the fields.

Under the North Dakota program local volunteer
help is used to a great extent and we depend upon local
physicians to collect blood from the donors. Thus far
this system has proved satisfactory. Not only does it
cut down the expense of the program; we find also that
the donors are more responsive and prefer that their
local physicians procure the blood. The only disadvan-
tage is that this method limits the number of communi-
ties in which clinics can be held. Many small towns have
requested an opportunity to hold a blood donor clinic
but must be refused because they lack a physician. How-
ever, these communities have a depot in close proximity,
so that plasma is available to them.

The enrollment of volunteer donors is always handled
through some local organization. A date for holding a
clinic or clinics is generally suggested by the director of
the program. Usually some civic or commercial organi-
zation or the local hospital is selected as a sponsoring
agency. In this way the clinic becomes a local function.
The sponsoring agency is responsible for the enrollment
of donors, the registration of donors at clinics, the fur-
nishing of volunteer help to assist with the clinics, the
selection of a suitable place for the clinic, the canteen
service, and all publicity. The type of publicity varies
in each community and depends a great deal on the
sponsoring agency.

Clinics are held in easily accessible public buildings,
such as churches, schools, memorial buildings, and hos-
pitals. Hospitals are preferred when there is only one
in a community, although some of our best clinics have
been held in other public buildings. In the larger cities
donors always seem a little hesitant about attending a
clinic when it is held in a hospital, although this has not
been found true in the smaller places. Volunteer help
is obtained from nurses’ aides, hospital staff nurses, stu-
dent nurses, and trained nurses who have become house-
wives. We have had no difficulty in obtaining sufficient
volunteer help to assist in running efficient clinics. On
the appointed date the Health Department sends out a
mobile unit, which carries all the necessary supplies for
the operation of the clinic. Generally two technicians
accompany the director and the unit to assist the local
people in conducting the clinic. Clinics are generally
held from 8:30 a.m. to 11:30 a.m. On some occasions
evening clinics starting at 6:00 p.m. have been held.
Our experience has shown that evening clinics are less
desirable, because many of the donors fail to obey in-
structions and eat before appearing at the clinic. Plasma
obtained from donors who have eaten, especially those
who have eaten fatty foods, within four hours of report-
ing at the clinic is generally not satisfactory for use.

The size of any given clinic depends a great deal on
the quota of donors set by the director and the physical
setup of the clinic. We have found that we can average
four donors per bed per hour, including registration and
physical examination. From this figure we can estimate

map r

BLOOD DONOR CLINICS

Map I. Showing distribution of 62 clinics in 25 North Da-
kota communities.

the number of beds and donors for each clinic. As a
general rule we set up a minimum of 50 donors and a
maximum of 90 for any given clinic. During the first
year, however, our smallest clinic was 36 donors and the
largest 142 donors. We have found that with one physi-
cian a five- or six-bed clinic is desirable, although when
space is available we like to have ten beds, because the
length of the clinic is then shortened.

Prior to each donation, a physical examination cover-
ing hemoglobin, blood pressure, pulse, and temperature
is given. Donors also fill out a registration blank, an-
swering specific questions regarding illnesses. A sero-
logic test for syphilis is run on each sample of blood
before it is used.

The canteen service, handled by the local sponsoring
agency, provides fruit juice before the blood is taken and
coffee and doughnuts afterward. The main reason for
the canteen is that it keeps donors under observation for
about fifteen minutes, in the event that any untoward
reaction develops. Each donor receives a card certifying
that he or she has rendered a public service to the State
of North Dakota.

No attempt has been made to create a large reserve
supply of plasma. Clinics have been scheduled to meet
the needs of the state, to provide an available supply in
all depots for routine use, and to keep a reserve in the
main laboratory for emergency cases.

Thus far we have held 62 clinics in twenty-five com-
munities, with a total registration of 3396 donors. Map I
shows the distribution of these clinics. It will be noted
that the mobile unit has covered a fairly representative
portion of the state. The distance of clinics from the
processing laboratory varied from those held locally to
those held in Dickinson, which is 380 miles from Grand
Forks.

Approximately 10 per cent of those who registered at
the clinics were rejected at the time of the physical ex-
amination. Rejections were for various reasons, primarily
low hemoglobin.

Every consideration is given to the donors, especially
those who are inexperienced and likely to be somewhat
timid. We advise the physician to make no attempt to
procure blood if the donor has extremely small veins.
We also recommend that if trouble is experienced in

The Journal Lancet

doing the venipuncture no further attempt should be
made, since we have found that a few hematomas can
be detrimental to succeeding clinics. It is important to
exercise caution in caring for the donor’s arm after dona-
tion has been made, as a bleeding arm at the canteen
can at times cause much confusion. We use a dry
sponge bandage covered with a piece of elastoplast,
which holds it tight.

Collection and Transportation of
Blood Samples

Local physicians in communities where clinics have
been held have been very successful in procuring blood
from donors. Some criticism has been made because we
do not employ a full-time physician to do all the bleed-
ing. However, we have felt that our system of getting
local physicians on a volunteer basis has been satisfac-
tory. We have found that donors prefer to have their
own physicians and are relieved when they find that a
strange doctor is not going to procure the blood.

The technique used at our clinics employs gravity for
collection of the blood. It is simple and economical,
as all parts of the assembly are reusable. After the ad-
ministration of a local anesthetic, 500 cc. of blood are
collected with a 16-gauge needle. This allows the blood
to be collected at the rate of approximately 100 cc. per
minute. When the full amount of blood has been col-
lected the needle is removed from the vein. The blood
remaining in the tube is collected in a small vial (5-6
cc.) for a Wassermann test.

At the conclusion of each clinic blood samples are
transported to the Public Health Laboratory in Grand
Forks for processing into dry plasma. The blood sam-
ples are placed in ice chests and are either carried to the
laboratory by automobile or shipped by express when
train connections are satisfactory. Each chest holds 18
samples of blood and has a removable tray holding suf-
ficient ice so that samples transported 300 miles within
a period of 18 hours have kept satisfactorily. As soon
as the blood is received in the laboratory it is placed in
a refrigerator.

Laboratory Procedure

It is not the purpose of this paper to give the exact
techniques employed in either the preparation of donor
bottles, the collection of blood from the donor, or the
steps involved in preparation of dried plasma. However,
a brief discussion of these essential steps may be of value.
Detailed information can be found elsewhere.3,3

Separation of Plasma. Centrifugation is used to sepa-
rate the plasma from the blood. This procedure is gen-
erally carried out within 18 to 36 hours. In accordance
with set standards all our plasma is in the frozen state
within 72 hours after blood has been collected from the
donor. We have three blood centrifuges, capable of
handling four bottles each. The bottles are carefully
balanced and are centrifuged for one hour at approxi-
mately 2200 r.p.m.; thus 12 bottles of blood can be
handled every 1 1/2 hours.

Pooling and Dispensing. It is the consensus that un-
diluted liquid plasma should be pooled in order to reduce
the titer of the agglutinins present. Therefore, after
centrifugation the plasma is drawn off the separated

January, 1946

bottles into a pool. At the beginning of the program
we were pooling approximately 15 samples into one pool,
but at present we are using a larger pool, consisting of
36 to 40 samples. After the plasma has been pooled a
preservative (1:50,000 dilution of phenyl mercuric bo-
rate) is added to each pool. The pool is then shaken and
allowed to set overnight, after which it is dispensed into
the final container in 250 cc. amounts.

During the dispensing process bacteriologic cultures
are taken to determine whether or not the plasma is
sterile. Cultures are made in liquid thioglycollate me-
dium at the beginning, middle, and end of each pool.
These cultures are then placed in a 37°C. incubator and
observed over a period of seven days.

Freezing of Plasma. After the plasma has been dis-
pensed into the final container it is frozen by a method
known as shell freezing, accomplished by the use of a
portion of the plasma dehydrating unit. The shelling
apparatus is an insulated metal pan containing cooling
coils and a mechanical device for rotating the bottles.
The rotating wheels are so arranged that the bottles are
rotated slowly ( /2 to 1 r.p.m.) with 12 mm. immersion
in alcohol, cooled to — 30°C. Shell freezing is a very
important step in the process, and unless it is done prop-
erly inadequate drying will result. The freezing appa-
ratus will handle 12 bottles every hour. After they are
frozen, the bottles of plasma are placed in a low tem-
perature ( — 20°C.) cabinet until they are desiccated.

Drying of Plasma. Under our system desiccation
from the frozen state takes place in the final container.
This method is preferred because it provides for maxi-
mal preservation of all elements of the plasma, maximum
solubility, and minimal opportunity for contamination
during the drying process.

The standard dehydrating apparatus is capable of dry-
ing 24 bottles of plasma every 20 to 22 hours. The
method used for dehydrating plasma is completed in an
efficient, practical apparatus and produces a product
which in all ways complies with the regulations of the
National Institute of Health. The product obtained,
when regenerated for administration, is as nearly as pos-
sible identical with the original material.

The Strumia 3 method is simple and economical and
the apparatus is so designed and operation so controlled
as to be constant, thus insuring a uniform product. The
resultant dried plasma is a light porous material of am-
ber color, containing a maximal content of complement
and of prothrombin.

After drying, a vacuum sufficient to draw in up to
350 cc. of restoration fluid is created in each bottle. The
rubber stoppers are then covered with gel caps and
labeled. Before any plasma is released for use, further
tests are made to insure its safety for intravenous admin-
istration. Toxicity and sterility tests are made on pilot
bottles from each pool, and if they are satisfactory all
plasma prepared in that batch is released for distribution.

Restoration Fluid. The laboratory also prepares the
fluid for restoring the dried plasma to the liquid state
for administration and distributes it with each unit of
plasma. At present a 0.1 per cent citric acid solution is
being used. It has been pointed out in the literature that

restoration with 0.1 per cent citric acid will give a fluid
having a pH varying from 7.4 to 7.8, whereas with dis-
tilled water the pH varies from 8.2 to 9.3. Pyrogen
tests are run on each batch of fluid prepared before it
is released for use.

Intravenous Set. An intravenous administration set
is furnished with each unit of plasma distributed, except
to the larger hospitals. It is felt that the lack of neces-
sary precautions in the proper preparation of administra-
tion sets will tend to discredit the operation of the pro-
gram, since it is the common inclination to ascribe pyro-
genic reactions to the plasma rather than to improperly
prepared equipment. Thus far our system has worked
out satisfactorily.

Distribution of Plasma

Under the North Dakota program a complete pack-
age of plasma is distributed. Each package sent out con-
tains one bottle of dried pooled normal human plasma,
one bottle of 0.1 per cent citric acid solution for restora-
tion of the plasma to the liquid state, and a complete
intravenous administration set and directions for its use.
This complete unit makes it possible for a physician to
administer plasma in an emergency, eliminating the neces-
sity for moving patients to a hospital. This is important
in North Dakota because of farm accidents and the lack
of adequate hospital coverage in the state.

For a program of this type to be successful the prod-
uct must be available to as many people as possible all
the time. Therefore, the first objective of the program
was to make supplies of plasma available in every part
of the state. Map II shows the distribution of plasma
during the first year. Plasma supplies are located in
44 hospitals, 3 drug stores, and the offices of 31 private
physicians, making a total of 78 depots in 49 of the
state’s 53 counties. These depots constitute our mobile
reserve which can be shipped to other communities to
meet emergency needs. Such a wide distribution is im-
portant if the program is to serve its purpose — that of
having plasma available to everyone.

Thus far in the program, 2400 units of plasma have
been distributed. The amount of plasma located in each
station depends somewhat on the normal supplies needed
in the routine practice of the local physicians, plus a
sufficient number of units for emergencies. As soon as
reports are received in the laboratory on the use of
plasma, these units are replaced with others. Thus pre-
determined supplies are maintained in the field.

The Use of Plasma

The recognition of the value of human blood plasma
as a therapeutic agent is one of the outstanding advances
of medical science in recent years. The use of human
blood plasma is now firmly entrenched as an important
factor in the modern practice of medicine. Its thera-
peutic value has been definitely established by both ex-
perimental and clinical observation.

In military medicine plasma has been used mostly to
combat shock due to traumatic injury. However, in the
civilian practice of medicine plasma has been used with
success in other conditions, such as hemorrhage, opera-
tion, obstetrical complications, burns, hypoproteinemia,
and infections, as well as in the prevention and treat-

The Journal Lancet

map n

DISTRIBUTION OF PLAbMA

Map II. Showing distribution of plasma in first year.

ment of measles, scarlet fever, mumps, pneumonia, and
other infections which do not respond to specific treat-
ment.

The most spectacular results with plasma are seen in
the treatment of traumatic and burn shock. The ready
availability of plasma is resulting also in better preopera-
tive preparation of surgical patients who show decreased
plasma proteins. Transfusions of plasma are often indi-
cated during convalescence because of continued deple-
tion of blood proteins. Convalescence is smoother and
shorter when the blood components are kept within the
normal limits.

The use of plasma is extremely simple, requiring no
complicated transfusion apparatus. Plasma, properly pre-
pared from citrated blood collected from healthy donors,
can be administered intravenously to patients without
regard to blood grouping or cross-matching. Properly
prepared plasma can be administered without causing
untoward reaction. Reactions following the administra-
tion of pooled liquid human plasma are chiefly of ther-
mal and allergic types.4 Our experience has been that
reactions of the thermal type are largely preventable if
scrupulous care and detailed attention are given to the
prevention of pyrogen contamination in the laboratory.

The first plasma prepared under this program was
sent out on August 27, 1944. Thus far 2400 units of
dried plasma have been sent out from the processing
laboratory. In the first year* of operation reports re-
ceived show that 1380 units were used on a total of 746
patients. Table I gives a classification of the types of
cases on which plasma was used. As would be expected,
the greatest number of units of plasma were used on
postoperative shock patients. One can readily see that
in the civilian practice of medicine there is a large variety
of medical cases for which plasma is indicated and can
be used to good advantage. Judging from reports re-
ceived, we feel that no plasma was used indiscriminately;
rather it was used where it was distinctly beneficial to the
patient. This statement is made because there has been
some fear that plasma would be used indiscriminately
because it was free.

‘Reports received to October 31, 1945, show a total of 1700
units used on 920 patients.

map m

USE OF PLASMA

Map III. Showing that plasma was used in 35 of 53 coun-
ties and in 44 communities.

Plasma has been used rather widely over the state.
One of the first objectives of the program was to get a
wide distribution so that people throughout the state
would benefit from the program. Map III indicates that
plasma has been used in 35 of the 53 counties of the
state and in a total of 44 different communities. The
greatest amount is of course used in the larger urban
centers, but it is gratifying to note that it has been used
in the rural areas as well.

Chart I shows the use of plasma by months. On the
basis of one year this chart may not be of much signifi-
cance other than to show the month by month use.
However, when compared with future years it may be
possible to determine some pattern.

At the beginning of the program many hospitals had
supplies of commercial plasma and also small liquid
plasma banks. This fact probably accounts for the slow
beginning of the use of plasma. At any rate, it is inter-
esting to see the way in which the amount used increased
gradually from month to month. Eventually we may be
able to level off and ascertain with some degree of relia-
bility how much plasma will be used at any given time
during the year. With physicians returning from the
armed forces to private practice the use of plasma may
increase materially, since these physicians are better ac-
quainted with its advantages.

Cost of the Program

At the conclusion of the first year of operation the
blood plasma program is established on a sound financial
basis and is an economical project. In the beginning no
one could have given a reliable estimate of the cost of
operation for one year. The initial cost of basic equip-
ment and supplies has been high, but the equipment will
last for many years and most of the supplies are reusable.
The cost per unit of plasma for the first year was $12.56.
This figure represents the entire cost of the program.
The word "unit,” as used here, means a complete pack-
age, with intravenous administration set in approximately
75 per cent of the packages and the loan of Baxter drip
filters to the larger hospitals.

During the second year of operation it is estimated
that the plasma package will cost less than three dollars
per unit. It would appear to be proved that plasma for

January, 1946

TABLE I

Reports Received on the Use of Plasma
August 27, 1944 -August 31, 1945

Number of Number of

Condition Patients Units

Postoperative shock 263 415

Prophylaxis shock 2 1

Operative shock 29 46

Shock (unclassified) 9 16

Traumatic shock with marked hemorrhage 60 112

Traumatic shock without marked hemorrhage 46 65

Hypoproteinemia 46 218

Ectopic pregnancy with severe hemorrhage 9 16

Placenta praevia 17 28

Postpartum hemorrhage 71 103

Abruptio placenta 3 4

Caesarean section 3 8

Hemorrhage from abortion .22 26

Infection 30 47

Gastric hemorrhage 13 2 2

Miscellaneous hemorrhage ------- 17 2 5

Postoperative hemorrhage 9 16

Burn 3 4 98

Communicable disease 6 17

Miscellaneous 25 36

Not classified 12 16

* Unsatisfactory 17

Total 746 1380

* Wasted at time of restoration in hospital, prior to administration.

a state-wide program can be produced with considerably
less expenditure than would be necessary if it were pur-
chased on the open market.

We believe that if plasma had been purchased either
by the state or by private physicians and individual hos-
pitals such a plan would not have had the success our
program has had. By distributing plasma free of charge
the State Health Department is making plasma available
on a much wider basis, to be used wherever needed in
the state. Needless to say, many patients’ lives have been
saved, and the convalescence of many more patients
helped by having plasma available. If plasma had had
to be purchased, we should never have had the wide dis-
tribution that now prevails in North Dakota, because
the cost of such a program would have been prohibitive.

Conclusion

It is believed that the North Dakota State Health
Department’s free plasma service has adequately proved
that there is a need for this type of program in the
civilian practice of medicine. Through such a program
civilians can now have the use of a service developed for
the armed forces. No one who requires plasma need be
without it, as the general distribution of plasma, with
reserves over the entire state, makes it always available
for immediate use. The plasma service has saved the
people of North Dakota many thousands of dollars they
would have had to spend to purchase this material on
the open market.

The people of North Dakota have proved by their
cooperation in volunteering their blood that they are

Un.t* «F Pl»s ma Used

I*** - 1‘WX

Chart I. Showing use of plasma by months.

aware of what it means to have supplies of plasma avail-
able locally for immediate use. The medical profession
and hospitals have accepted the State Health Depart-
ment program with enthusiasm and regard it as a step
forward in the advancement of medical aid.

Production of plasma will be expanded to meet de-
mands, for there is evidence that the use of plasma will
increase as the program progresses. The increased bene-
fits to patients from the administration of plasma will
naturally extend its use. The return from the armed
forces of medical men cognizant of the value of plasma
will also increase its use in the state.

It is the firm conviction of the author that this type
of program should be set up in every state and that it
can be administered very effectively by a state health
department.

References

1. Alsever. John B.: Plasma reserves for civilian defense, their

distribution, control, preparation and clinical use. J.A.P.H.A.,
34:165 (Feb.) 1944.

2. Koons, Melvin E.: Free plasma for North Dakotans. Pub.

Health Repts., 60:4 (Jan. 26) 1945.

3. Strumia, Max M., and McGraw, John J.: A method and appa-

ratus for shell freezing and rapid drying of plasma and other
products from the frozen state by low temperature water
vapor condensation in vacuo. J. Lab. and Clin. Med., 28
(June) 1943.

4. Miller. Edward B., and Tisdall, Leslie H.: Reactions to 10,000

pooled liquid human plasma transfusions. J.A.M.A., 128

(July 21) 1945.

5. The operation of a hospital transfusion service. Technical Man-

ual No. 2220. Washington: Office of Civilian Defense,

March 1944.

6. Strumia, Max M.: Preservation of prothrombin in dried plasma.

J.A.M.A., 1 19:710, 1942.

7. Cohn, Edwin J.: Blood proteins and their therapeutic value.

Science, 101 (Jan. 19) 1945.

VICTORY CLOTHING COLLECTION

A Victory Clothing Collection appeal will be made in January, following up the 1945
collection, which provided some 25 million persons in the liberated countries with clothing.
Large as this number of persons helped through the generosity of Americans appears, it is
only a fraction of the number who still need help. Give clothing — all you can spare — in the
collection. It will help to maintain morale and health and to inspire the international friend-
ship needed to mold the brave new One World.

The Journal Lancet

Short Leg Backache

John M. Butler, M.D.

Hot Springs, South Dakota

AT the present time the medical and surgical litera-
ture is flooded with articles and discussions on
^ the subject of backache. The herniated disk is
considered responsible for most back and leg pains to-
day and it is gaining continually in popularity. One has
only to read the late papers of Dandy 1,2,3 of Baltimore,
a recent article by Keegan 1 of Omaha, and more re-
cently, a paper by Key ■' of St. Louis, to get the idea
that, with few exceptions, every case of backache has a
protruded disk as the etiologic factor.

Since the demonstration of the herniated intervertebral
disk as a definite pathological entity by Mixter and
Barr K in 1934, there has been a rapid development of
surgical technic for the treatment of this condition.
These developments in surgical technic have simplified
the operative procedure and shortened the period of con-
valescence until the risk of the operation is not nearly
as great as it was formerly. These advancements have
resulted in an increase in the number of surgical ex-
plorations for ruptured intervertebral disk to the point
where it has reached almost fad proportions. The lay
people are beginning to talk about disk protrusion in the
same way that they discussed their sacroiliac strain a
few years ago.

Lest we, as professional people, get to the point where
"we cannot see the trees for the forest,” it is consid-
ered timely to present this rather simple explanation of
many cases of backache for the consideration of those
men who first see the patient.

It is not the purpose or intent of this paper to enter
into any lengthy discussion of the subject of backache,
but instead, to call attention to a frequent cause of back-
ache which is often not recognized, or if recognized,
is disregarded and considered unimportant.

The cause of backache to which reference is made is
inequality in the length of the two legs and more spe-
cifically those cases of what might be called minor in-
equality where a difference of one fourth inch to one
inch exists.

The privilege of practicing in a city which has for
many years been looked upon as a spa-resort for this sec-
tion of the country has afforded considerable opportu-
nity to examine and treat the so-called "chronic case.”
These people naturally seek the spa because of long
standing disability of one type or another which has not
responded to the ministrations of their family physician.
Almost without exception these people have been in the
hands of many and various types of unorthodox prac-
titioners and usually state "they helped me but it did
not last.” Many of these people have been to the best
diagnostic and treatment centers and have failed to
receive the desired relief but have been permanently
relieved by the simple procedures to be outlined below.

Before entering into a specific discussion there are two
or three points that should be brought out from the

standpoint of physiology and anatomy. In the first place
the body is normally supported by bone with the liga-
ments to keep bone structure unified and to limit the
range of motion. In the second place, we have the mus-
cular system which serves the purpose of restoring the
bony segments to a state of equilibrium once this state
has been disturbed. Normally with the body in a stand-
ing position, the weight of the upper body is supported
by the spine and at the pelvis is transferred to the legs
so that the body weight is distributed equally between
the two lower extremities. Provided these two lower
limbs are exactly equal in length the horizontal plane of
the pelvis is parallel with the floor, and in this state the
spine rests on the pelvis in a line perpendicular to the
horizontal plane of the pelvis. The body weight is then
carried by the spine and transferred equally to the two
legs without the use of muscle action or ligament strain
to maintain body equilibrium. Just as soon as the paral-
lelism of the horizontal plane of the pelvis with the floor
is disturbed and the pelvis drops down on one side, the
spine can no longer remain in a perpendicular line and
maintain postural balance. In order then to maintain
this balance, the muscles and ligaments of the spine must
come into use. This results in ligamentous strain and
muscle spasm with the establishment of a pain and
fatigue-producing mechanism.

Barker ' in discussing backache due to faulty balance
states that "many of these backs do not give trouble
until some form of trauma has occurred.” The various
names that have been applied to the conditions falling
under this category are simple evidence of the fact that
they have been imperfectly understood. Back trouble
diagnosed as weak back, hysterical back, neurasthenic
spine, railroad spine, irritable spine, pelvic backache,
chronic lumbago, sacroiliac relaxation and more recently
fascitis are examples of conditions quite often due to the
above described mechanism. Barker ' states that "it is
probable that the majority of backaches falling into the
hands of the family physician fall within this group of
muscular imbalance.” These backaches are usually more
common in women than in men and are especially com-
mon among those who are chronically weak and tired,
and they are more often seen in the twenty to fifty
age group.

The symptoms of which these patients complain are
many and varied. Pain in some region of the back is the
most common and next in frequency is nervousness and
easy fatigability. Other complaints are inability to sleep,
pains radiating around the chest, pains in the legs and
knees, suboccipital head and neck pains and pains in
arms and shoulders. Pain of sciatic radiation is fre-
quently encountered. In the past three months seven
patients with sciatic pains have been cured by the therapy
outlined below.

The short leg is a common cause of muscle imbalance

January, 1946

or of the so-called postural imbalance in an apparently
otherwise healthy individual. Many authors of articles
on the type of backache here discussed stress the im-
portance of faulty posture and muscle spasm along the
spine as being the factor producing the pain, but search
of the literature has failed to find a single article which
even mentions the short leg as the basic cause of the
faulty postural balance.

Many of these patients who come to seek relief from
backache can be diagnosed merely by careful observation
of their gait and standing habits. In men, one frequently
sees that the belt of the trousers does not set parallel
with the floor but instead, tips to one side. In women,
one hip is more prominent and the hollow of the flank
is less on one side. One shoulder is, almost without ex-
ception, carried low and if fairly snug clothing is worn,
one can notice the scoliosis in the back. In watching
these patients walk, it is very easy to notice the heavy
step on the short leg side.

In examining these patients unclothed, all of the above
mentioned findings are exaggerated and more clearly
seen except those in reference to the way clothing is
worn. In addition to these, one can readily detect spasm
along the back muscles by palpation. Also, one finds the
patient must be asked to stand squarely on both feet for
he is prone to stand with the weight entirely on one leg
and use the other merely as a balance prop. Another
finding in these cases is the unilateral development of
an ankle valgus and a unilateral development of lower
extremity varicosities. The ankle valgus is usually on
the short leg side, whereas it has been impossible to
establish a rule for the side in which the varicosities
develop. It seems that varicosities develop according to
the standing habits of the individual — some prefer stand-
ing on the longer leg, others on the shorter one.

In further checking, one will notice that the posterior
spinous processes fail to fall in a straight line. As point-
ed out by Sever s, the posterior spinous processes should
align under a weighted string so held that the lower end
hangs in the gluteal cleft.

In determining the amount of shortening present, the
first check is leg measurement. A simple and fairly
accurate method of doing this is to have the patient lie
flat on the back, grasp the feet and exert a slight amount
of traction and ask the patient to lie relaxed with the
toes allowed to roll outward. Measurement is then made
from the anterior superior iliac spine to the lower border
of the internal malleolus of the ankle on each side. The
final check then is to have the patient stand without
shoes and build up under the short leg, with wooden
plates or with magazines, the amount necessary to raise
the low side of the pelvis until the horizontal plane of
the pelvis is parallel with the floor. Then check the
alignment of the posterior spinous processes. Sufficient
lift should be given to the short leg to level the pelvis
and be content regardless of the alignment of the spine,
for occasionally one will find a back with so much muscle
spasm that it will not align itself immediately but even-
tually will come back to neutral position after the pre-
cipitating strain has been removed. An article by Mock 9
stresses the fact that back braces and supports are abso-

lutely contraindicated in these cases, for the support thus
afforded causes more disability by producing muscle
weakness and atrophy.

After the amount of shortening has been determined,
the patient is instructed to compensate for this short-
ening by one of the following methods. In women, the
advice varies with the height of heels they are accus-
tomed to wearing on their shoes. A cuban type heel
fortunately is more commonly encountered and lends
itself more readily to alteration. To compensate for
one half inch difference they are asked to have one
fourth inch put on the heel of the short leg and remove
one fourth inch from the heel of the long leg shoe.
Often one can place a one fourth inch lift on the inside
of the short leg shoe. Any arrangement of alterations —
adding to a heel, cutting off a heel or a combination of
these two, or pads placed under the heel in the shoe
will usually accomplish the purpose in women, who are
more used to walking with the weight thrust more
toward the metatarsal heads.

In men, one cannot as a rule make great changes in
heel heights without running into difficulty. Conse-
quently, men are advised to have the shoe on the short
leg side half-soled and then make the heel adjustments
where the difference is one half inch. When the leg
shortness is greater than one half inch, it is better to
put more lift on the sole rather than to make too much
change in the heels alone.

Summary

Anatomical variation in the length of the legs of an
individual is a frequent finding in everyday practice.

Faulty posture resulting in muscle spasm is a frequent
cause of backache and is more commonly seen in women
than in men and in those who complain of being chron-
ically weak and tired. The short leg is a common cause
of faulty posture and muscle spasm in the back.

Every patient with chronic backache should be care-
fully checked for short leg and back muscle spasm.

Supports and braces are contraindicated because they
add to the disability of the individual by the creation of
muscle weakness and muscle atrophy.

Every patient with backache who has a short leg
should be given a therapeutic test by compensating for
the short leg as herein described before being submitted
to myelography or other extensive diagnostic tests or to
major therapeutic procedures.

References

1. Dandy, W. E.: Concealed Ruptured Intervertebral Disks.

A Plea for the Elimination of Contrast Mediums in Diagnosis.
J AM. A. 117:821 (Sept. 6, 1941).

2. Dandy, W. E.: Treatment of Recurring Attacks of Low

Backache without Sciatica. J.A.M.A. 125:1175 (Aug. 26, 1944).

3. Dandy, W. E.: The Treatment of Spondylolisthesis.

J.A.M.A. 127:137 (Jan. 20, 1945).

4. Keegan, J. Jay: Diagnosis of Herniation of Lumbar Inter-

vertebral Disks by Neurologic Signs. J.A.M.A. 126:868 (Dec. 2,
1944) .

5. Key, J. Albert: Intervertebral Disk Lesions are the Most

Common Cause of Low Back Pain with or without Sciatica. An-
nals of Surgery 121:534 (April 1945).

6. Mixter, W. J.. and Barr, J. S : Rupture of the Inter-

vertebral Disk with Involvement of the Spinal Cord, New England
Journal of Medicine 211:210 (Aug. 2, 1934).

7. Barker, Lewellys F.: Backache J P. Lippincott Co., 1931.
Chapter VII.

8. Sever, J. W.: Principles of Orthopedic Surgery, 3d Ed.,

Macmillan Co., 1940.

9. Mock, H. E.: Low Back Pain. Wis. Med J. 42:389

(April 1943).

The Journal Lancet

Some Common Skin Diseases and Their Treatment

Herbert C. Leiter, M.D.

Sioux City, Iowa

THIS paper is designed to be an unpretentious,
informal, practical discussion of the etiology, diag-
nosis, and management of some common skin dis-
eases as they are encountered in general practice.

Often it appears that skin diseases and those who try
to make a specialty of treating them do not rate too
high. We dermatologists are sometimes considered not
quite full-fledged physicians but some kind of narrow-
gauge practitioners, the legitimate target of more or less
good-humored jokes. You have perhaps heard the story
of the dermatologist who was asked by a friend why he
took up this specialty. He answered: "For three good
reasons. One, I don’t have to get up at night. Two,
my patients never die. Three, they never get well.”

And there is the story of one dermatologist, a pro-
fessor at a famous university, who took on some young
assistants subject to the promise that they would study
under him for three years before going into practice on
their own. One bright young fellow stayed only one
year before opening his own office. Bitterly reproached
by his former principal, he retorted: "It might take the
average man three years to find out the secret of skin
diseases, but it took me only one year. The secret is that
there are only two kinds of skin diseases: one is the kind
that gets well no matter what you do; the other kind
doesn’t get well no matter what you do.”

There is some truth in these jokes. It is true that skin
diseases are plainly visible and open to the examining
eye. There is no need to resort to complex diagnostic
procedures like X-ray. Still, it is sometimes difficult to
come to an exact diagnosis, because lesions that look
similar may be of very different origin. The skin reacts
similarly to very different kinds of injuries and insults.
For instance, scarlet fever, a systemic infection, produces
a rash that is in appearance exactly the same as a mer-
cury dermatitis from the external application of am-
moniated mercury ointment on a sensitive skin. Again,
it is sometimes difficult to distinguish between a chronic
patch of psoriasis and eczema. A common cold sore may
look like impetigo; or if you should see this same lesion
on the lip of an older person your first thought might
be that you had a malignancy to deal with. Moreover,
lesions of leukemia, syphilis, Hodgkin’s disease, or tuber-
culosis produce skin lesions that may look very similar.

This may sound complicated and confusing, but actu-
ally the number of skin diseases commonly seen in gen-
eral practice is limited. With some experience they can
usually be diagnosed fairly easily and treated success-
fully with means at the disposal of the general prac-
titioner.

In any case of skin disease it is important to take a
short history. It pays to do so for several reasons. We
find that certain types of skin disease, especially eczemas,
do affect more often a certain type of personality — the

Read before the Yankton District Medical Society, Yankton,
South Dakota, September 20, 1945.

nervous, high-strung, ambitious, overactive type, often
bordering on the neurotic. A little conversation with the
patient when taking the history will often prove enlight-
ening in this respect. It will reveal the patient’s frame
of mind and possibly enable the physician to extend a
helping hand. Such help sometimes does more good than
any salve or paste, and no one is better qualified to prac-
tice this bit of psychotherapy than the general practi-
tioner, who, intentionally or otherwise, is constantly giv-
ing such help.

The patient should be questioned about his occupa-
tion, for certain occupations expose those who follow
them to certain skin hazards. I need only mention the
eczema of bakers and painters; dermatitis in florists and
gardeners, for instance from primroses; ragweed derma-
titis in farmers; and erysipeloid in butchers. If the occu-
pation gives no indication, the avocation or hobby may
do so. Thus the patient’s gardening hobby may be
the clue. Also, hereditary factors (atopic family-history)
and factors that might point toward an infectious origin
of the condition under examination, such as similar cases
in the patient’s surroundings, should not be overlooked
when taking a case history.

I shall discuss a few of the more common skin dis-
eases: scabies, pyogenic infections, acne, warts, fungus
infections, drug eruptions, and contact dermatitis.

Scabies. Scabies is due to infestation with a mite, Sar-
coptes scabiei, so small that it can barely be seen with
the naked eye. It burrows tunnels in the skin, and lives,
feeds, multiplies, and deposits its metabolic products in
the burrows. The clinical picture is a dermatitis consist-
ing of red papules and dark grayish burrows, distrib-
uted especially between the fingers, on the flexor side of
the wrists, in the armpits, on the breasts, and around the
navel, buttocks, and genitalia. In neglected, long-stand-
ing cases the whole body, with the exception of the face,
scalp, and neck, is affected. Crusty, pussy lesions of
secondary impetiginization from scratching are frequent,
as well as secondary eczematization.

The infection usually occurs through intimate bodily
contact, such as sleeping in the same bed, wearing the
same clothes, or possibly from riding on the same seat
in trains or cars. It is improbable that such casual con-
tacts as writing with the same pencil or pen are sufficient
to transfer the disease. Owing to the tremendous in-
crease in travel and migration in and out of the country
due to military transfer, travel of migratory and war
workers, and overtaxed and therefore inadequate hotel
accommodations, the condition increased greatly during
the war. Scabies used to be a disease of the lower classes
and unclean persons and it was highly embarrassing to
both physician and patient to diagnose it in a lawyer,
doctor, or society woman, but this is no longer so and
scabies now affects persons in all walks of life.

The history is typical. There is intense itching, always

January, 1946

worse at night after the patient becomes warm in bed.
Usually several members of the family are afflicted. It
is essential that all persons in the family who may have
contracted the disease should be treated, and treated at
the same time. Otherwise a vicious cycle is established,
one member after another will be affected, and reinfec-
tions will occur.

Treatment should begin with a thorough tub bath.
The patient should soak in the bath for some time and
use soap and a brush in order to open the lesions. Thus
the medicaments used can penetrate into the lesions and
reach the parasite. The best drug for treatment used to
be sulphur ointments, 10 to 20 per cent, possibly with
balsam of Peru; the salve was massaged in all over the
body, with the exception of scalp and face, twice a day
for a total of four to six treatments. This treatment is
now being replaced by lotions containing benzyl benzoate,
which are much cleaner in application and of which two
applications usually suffice. The patient should not
change his clothing or wash during the treatment. A
cleansing bath should be taken twelve to twenty-four
hours after the treatment is completed. At that time all
clothing and bedding should be changed and the soiled
clothing and bedding should be boiled, dry cleaned, or
pressed.

Pyogenic infections of the skin are common, and most
common among them is impetigo , which is a staphylo-
coccic or, less commonly, a streptococcic, infection. The
infection is superficial. The first lesion is a little vesicle
filled with clear fluid which soon breaks and leaves a
profusely oozing raw surface. The serous exudate
spreads the infection to the surrounding area, where new
lesions soon appear. The exudate dries fast and soon
covers the lesions with thick, honey-yellow or sometimes
brownish-colored crusts. The oozing raw surface can be
seen after removal of the crusts.

This highly contagious condition is common in chil-
dren but is not exclusively a children’s disease. It is seen
also in adults and even in very old people. Usually all
children of the family show the infection at the same
time. The lesions are usually on the face, and frequently
also on the scalp. Through contact with the fingers the
infection may be spread over the body.

In treating impetigo all scabs and crusts must first be
removed. Otherwise the drugs applied will not reach the
site of infection. The crusts can be removed by wash-
ing with soap and water, but preferably are removed
with tweezers or a similar small instrument. This process
sometimes entails a struggle with the little patient. Some
bleeding from the lesions at this time is unimportant.
After removing the crusts — and they should be removed
at least twice a day — the medicine should be applied to
all lesions and a well-fitting dressing bandaged on.
When the lesions are on the face a muslin face mask
will often be necessary.

Ammoniated mercury, 5 or 10 per cent, the drug of
choice until recently, is being replaced by 5 per cent
sulfathiazole ointment. In my experience the sulfathia-
zole ointment definitely clears up the lesions more satis-
factorily, but is also more prone to produce a dermatitis,

owing to sensitivity to the drug. Painting of the lesions
with a 2 per cent aqueous solution of gentian violet is
popular and effective, but messy. Tub baths with potas-
sium permanganate, 1 to 10,000, may facilitate the re-
moval of crusts. Cleanliness is essential to prevent spread-
ing the infection to other members of the family, espe-
cially to the mother who is treating her infected child
at home.

Barber’s itch, or sycosis vulgaris, a condition the practi-
tioner often has to battle, is a staphylococcic infection of
the hair follicles, showing as a little pustule, more or less
inflamed, around each hair of the bearded area. In rare
instances other hairy surfaces may be affected. In acute
fulminating cases inflammation may be extreme, with
redness, swelling, and pussy exudation from the whole
area. The infection is often, but not invariably, con-
tracted in barber shops. Scratching with contaminated
fingernails is enough to start the condition.

Treatment is sometimes very difficult and tedious, and
relapses are frequent. In the acute case hot wet packs,
with 3 per cent boric acid solution or one half per cent
aluminum acetate solution many hours a day will quickly
reduce the inflammation. After the acute phase is over
every affected hair must be taken out with tweezers.
Disinfectant salves, like ammoniated mercury ointment,
or lotions with sulphur or cinnabar or ichthyol, are help-
ful, especially if combined with hot packs. Sulfonamides,
given internally, are valuable, and penicillin often gives
dramatic relief.

If these methods do not help and the condition con-
tinues to flare up, the patient should have X-ray treat-
ment, with or without temporary epilation. X-ray treat-
ment often achieves results when everything else has
failed. Vaccines may be used to advantage.

Hydrosadenitis. All that has been said about sycosis
vulgaris holds true for hydrosadenitis, an infection of the
sweat glands of the axillae. The treatment is identical,
with the exception that surgical intervention is more
often necessary in hydrosadenitis.

Acne. Every busy practitioner will see many teen-age
boys and girls seeking treatment of the acne of ado-
lescence. The cause of this disorder is probably to be
sought in the somewhat unbalanced activity of the endo-
crine glands at this age, which leads to overstimulation
of the sebaceous glands in the skin, especially of the
face, and sometimes also the chest and upper back and
shoulders. This condition in turn results in a more
abundant secretion of oil and a greasy appearance of
the affected parts, the so-called seborrhea. The black-
heads that result plug up the openings of the sebaceous
glands and prevent further passage of oil from the gland,
which will overextend and act as a foreign body, causing
an inflammation visible as a red papule on the face. If
secondary infection of this mass in the obstructed gland
takes place little pus-containing abscesses will be formed,
and then we have what is commonly called a pimple.
This condition is highly embarrassing to the young boy
or girl, and often causes unhappiness and personality
difficulties entirely out of proportion to the actual dis-
figurement.

The Journal Lancet

It is imperative that the practitioner have some means
at hand to help these young persons. Even if the results
are sometimes disappointing the patient will be thankful
if the doctor makes an effort to help him. Treatment
consists first in the elimination of such aggravating fac-
tors as constipation, stomach disorders, irregularity of
menstruation, anemia, and foci of infection. A diet con-
taining plenty of fresh fruits, vegetables, and lean meat,
and restriction of carbohydrates and fats should be insti-
tuted— though the actual value of such a diet in over-
coming acne may be disputed. Plenty of sunshine and
outdoor exercise and congenial company should be rec-
ommended, and, in well-to-do families, possibly removal
to a high altitude region.

Local treatment consists of a weekly shampoo, possibly
with tincture of green soap, at least two daily washings
of the face with soap and water to remove excess oil —
a sulphur soap is often helpful — and nightly application
of a sulphur lotion, such as lotia alba, or a calamine
type lotion containing 2 per cent resorcin and 10 per cent
sulphur. Face creams should be avoided.

The patient should be strictly forbidden to pick at the
lesions, but small abscesses should be opened by the phy-
sician with fine incisions, to avoid unnecesary scarring,
and comedones should be extracted at the office. Auto-
genous or stock vaccines are often employed, but not
too much should be expected from their use. Ultra-
violet treatments are of decided value in many cases.

In stubborn cases the patient should if possible have
X-ray treatments, which often give good, permanent re-
sults when other means have failed. The treatments
should of course be attempted only by those experienced
and qualified to give them.

Warts. The common wart may be single or multiple,
small or large. It may be found anywhere on the body,
but occurs most commonly on the hands and face. Warts
appear to be the result of a virus infection. Not only
can they be spread through inoculation of particles from
warts, as in shaving warts on the bearded area of the
face, but it is possible to cure warts with vaccines pre-
pared from warts that have been removed, then crushed
and filtered.

The wart can be extremely capricious in response to
treatment. Sometimes suggestion alone is sufficient to
cause the wart to disappear. This may account for the
many magic cures for warts, varying from charms and
incantations to the application of various inactive but
usually unsavory concoctions. It has been proved that
warts do at times disappear without treatment. Method-
ical painting with some such dye as gentian violet, which
in itself would not cure the wart, can bring about a cure
if the patient can be convinced that it will cure him.
On the other hand, even the most vigorous surgical
treatment will not eradicate a wart in some instances,
to the despair of both patient and physician, and an old
wart will sometimes appear again even after thorough
destruction in the scar.

Ordinarily treatment should be directed toward the
destruction of the single wart or multiple warts either
with chemicals like trichloracetic acid or formalin, or

surgical curetting, possibly with subsequent cauterization
with an acid, actual cautery, or by coagulations or desic-
cation with diathermy. Whatever method is employed,
one should take care to destroy the wart without injury
to the tissues underneath, to avoid delay in healing and
undue scarring.

In instances where it is especially important not to
cause injury — for example, when treating a wart on a
violin player’s fingers — it is often possible to effect a
cure by means of X-rays or radium. The stubborn and
painful plantar wart may be cured in the same way, and
often responds better to X-ray or radium than to de-
struction by surgical means, and with much less discom-
fort to the patient.

Fungus infections. The following classification of skin
diseases due to fungus infections is not a scientific one,
but merely the one that seems most practical and least
confusing for the purpose.

Epidermophytosis , the condition called athlete’s foot,
consists of a superficial invasion of the skin of the feet,
especially between the toes and on the soles, with certain
kinds of fungi. Clinically we find painful cracks between
the toes, maceration and inflammation of the skin be-
tween the toes, at times with a cheesy odor, and super-
ficial ulceration after removal of the macerated skin.
There is sometimes considerable redness and swelling,
pain, and incapacitation due to secondary infection.
There are often vesicular and pustular eruptions on the
soles; that is, small blisters filled with a clear fluid or
pus, with more or less inflammation and redness of the
skin of the soles. In other cases we find only redness and
more or less pronounced scaliness of the soles. Sometimes
we find both the pustular and the scaly form at the same
time. There is sometimes cracking and, in chronic cases,
very marked thickening of the skin. In the acute phase
the condition is very tender and painful, owing to inflam-
mation. In the more chronic cases itching is a promi-
nent feature. At times the palms of the hands and the
fingers may be affected in the same way, owing to infec-
tion with the same organism or absorption of toxic
products.

In treating this common disorder one basic mistake
must be avoided. While the condition is in the acute
phase, with considerable inflammation, no strong medica-
ments should be used, for they tend to aggravate the
condition. In the acute phase the patient should if pos-
sible be off his feet for a few days. Cold wet packs with
3 per cent boric acid solution, potassium permanganate
solution, or some other mild disinfectant solution should
be applied for many hours each day. Pus pockets should
be opened and dead skin should be carefully removed.
In the intervals between wet packs, soothing, slightly dis-
infectant salves, such as boric acid ointment, should be
used. After the acute phase has passed more active
treatment may be instituted, such as applications of
Whitfield’s ointment, of one fourth, then one half, then
full strength, and finally double strength. Or some other
approved, strong fungicidal remedies in the form of
salves or alcoholic solutions may be used. Soap and
water are not helpful in this condition.

Tinea cruris, or gym itch. Fungi often attack the

January, 1946

moist area in the groin, and sometimes in the armpits,
under the breasts, or in the folds of the abdomen of
obese persons. This condition is called tinea cruris, or,
more popularly, gym itch. The condition is aggravated
by summer heat and marching. There are well-defined
red, inflamed patches in the groin, at times slightly ele-
vated and pustular. The scrotum and penis and the area
around the rectum are sometimes affected. The same
condition is seen in the other areas affected. Itching is
a prominent feature and is sometimes extremely annoy-
ing, though in very acute cases the patient will complain
more of a burning pain. In acute cases treatment con-
sists of cold wet packs and a soothing lotion, such as
calamine lotion. After the acute phase an active fungi-
cidal drug such as Whitfield’s ointment or a lotion with
sulphur, resorcin, and salicylic acid should be used. Even
mild chrysarobin lotions may be used to great advantage.
Soap and water should be avoided.

Tinea corporis, or ringworm of the body. The prac-
titioner is often called upon to treat this fungus infec-
tion of the hairless skin. Clinically it shows more or less
inflamed, reddish or brownish scaly patches, at first small,
about pea-sized, then growing up to the size of a quarter
or even a dollar. The condition usually starts with one
spot and spreads to new patches. The inflammation may
be moderate or considerable. Little pus pockets or blis-
ters may be visible on the border of the lesion. As the
lesion increases in size it heals in the center, thus form-
ing a red, scaly ring with normal skin in the center and
giving the condition its name of ringworm. In rural
areas the condition is frequently contracted from cattle.
It is also contracted from cats and dogs, which sometimes
suffer from fungus infections.

One encounters also a different type of lesion which is
accompanied by much more inflammation and causes
boil-like lesions with considerable swelling and drainage
of pus from numerous small abscesses.

The superficial type is easily amenable to treatment,
which is similar to that for tinea cruris. The deep type,
however, responds better to hot wet packs, combined if
possible with X-ray therapy.

Kerion celsi. The hairy parts of the body — the scalp
and in grown men the bearded areas of the face — may
also be the site of fungus infections. Farm youngsters
with scalp lesions the size of a quarter up to the size of
the palm, or even larger, are encountered. The affected
area of the scalp will be badly swollen, the lesion raised
up to one inch above the surface of the rest of the scalp,
with much inflammation. Most of the hairs will have
fallen out or will be loose; pus will be draining profusely
from many small openings and partly dried on in crusts.
The lesion has a boggy feeling to the touch. However,
actual abscess formation rarely occurs. The lesion is spec-
tacular. The lymph glands on the back of the head are
usually swollen, and the temperature is often high and
the patient ill. Similar lesions are seen in the bearded
area of grown men, especially farmers or cattle men.
This condition is nearly always contracted from infected
cattle.

Though these lesions seem so dramatic, the treatment
is usually simple and a cure may be achieved without

resorting to heroic measures. Treatment consists in the
persistent use, day and night, of continuous hot wet
packs with any of the solutions commonly used for hot
compresses. This treatment will reduce the swelling in
the course of a few weeks. Usually there will be very
little scarring and most of the hair will grow in again
in the affected places. Mechanical removal of the hairs
from the affected areas sometimes hastens recovery.

Another form of fungus infection of the scalp, much
less spectacular than these so far discussed, is accompa-
nied by relatively little inflammation, and may be com-
bined with patches of ringworm on other surfaces of the
body. The inflamed patches, varying from the size of a
penny to a half dollar, are sometimes slightly red, scaly
with partial baldness, and in other cases grayish, with
little scaliness. This condition is seen exclusively in chil-
dren. It is sometimes extremely recalcitrant and the most
meticulous treatment with fungicidal salves will not
cure it. It is worth trying to treat the scalp for several
weeks as follows: Clip the scalp and treat with ammo-
niated mercury ointment with the addition of salicylic
acid, or with a sulphur ointment and daily shampoos
with tincture of green soap. If no definite improvement
is visible after a few weeks it will be necessary to refer
the case for an exact mycological diagnosis, made micro-
scopically and by culture. If necessary the whole scalp
should be treated with X-ray in such a way as to cause
a total loss of hair about three weeks after treatment.
Six or eight weeks after the hair has been shed it will
start to grow back. Our local remedies take effect in
this interval between the loss and the regrowth of the
hair, and it is only during this interval that a cure can
be effected. However, self-healing takes place in these
cases as soon as the patient reaches puberty.

This condition is not commonly seen in rural areas,
where the ringworm infections of the scalp due to a
fungus pathogenic for animals are more usual. How-
ever, in the large cities of the East, and recently in the
Midwest, this type of highly infectious scalp infection is
prevalent. The organisms causing the disorder are pri-
marily human pathogenes and hence do not cause enough
reaction in the affected person to cause self-healing or
to assist materially in the healing of the condition. For
this reason it is necessary to treat these cases with X-ray
epilation.

Most ringworm infections of the scalp with animal
pathogenic fungi, of the sort commonly encountered in
rural areas, clear up satisfactorily with local treatment,
because they cause so much reaction from the side of the
system of the patient that this reaction, together with our
local application, effects a cure. Hence it is unnecessary
in such cases to resort to X-ray epilation.

I have not considered microscopic examination or cul-
tures of fungus-infected material, nor examination of the
scalp under the so-called dark light, not only because
these procedures are not at the command of the general
practitioner, but also because in the typical case of ring-
worm commonly seen in rural areas the general practi-
tioner can establish a diagnosis and institute appropriate
treatment without recourse to these procedures.

Drug eruptions are seen fairly frequently by the gen-

The Journal Lancet

eral practitioner nowadays. They may be due either to
drugs administered by the physician or to some medi-
cine the patient has been getting from the drug store
and taking on his own account. Since the advent of the
sulfa drugs the former kind of rash is much more com-
mon, for sulfa drugs are prescribed so often at present
and cause reactions so frequently that every practitioner
will be confronted with a case of sulfa eruption at some
time or other. Moreover, there is almost no drug that
will not cause an eruption in some individual.

Drug eruptions may be classified into those that. re-
semble measles, those that look like scarlet fever, and
those that are like urticaria. They are usually distributed
over the body and are frequently associated with much
itching. Slight fever, malaise, and headaches are asso-
ciated features. Desquamation after subsidence of the
rash is frequent. Severe cases may show severe exfoliative
dermatitis, with redness, swelling, oozing, crusting, and
scaliness of the skin of the whole body.

Drugs that not infrequently cause eruptions are too
numerous to mention. The more common ones are sulfa
drugs, quinine, aspirin, barbiturates, coal-tar derivatives,
including many laxatives, antineuralgics, and headache
tablets, gold, and neoarsphenamin and other arsenical
drugs. Serums for lockjaw, pneumonia, and diphtheria
may cause serum sickness associated with hives and a
rash like that of scarlet fever or measles. A similar con-
dition is sometimes caused by an injection of penicillin.

If a physician has prescribed a medicine likely to cause
a drug eruption the diagnosis will be established easily.
However, in any itchy, generalized skin eruption of un-
certain origin the possibility of a drug eruption should be
kept in mind and the patient should be questioned about
the use of drug store remedies.

In treating drug eruptions a diagnosis is essential in
order to effect a withdrawal of the offending drug. No
sedative that might possibly aggravate the condition
should be given. Oatmeal baths, the application of such
soothing lotions as calamine lotion, and the avoidance
of soap and water will usually clear up the condition in
a week or two. In cases of severe exfoliative dermatitis,
however, the course will be doubtful and the prognosis
doubtful.

It may be worth while to mention that drug eruptions
may be caused by external application of, for example,
blue ointment or ammoniated mercury ointment, and
that sulfa ointments frequently cause skin irritations.

Contact Dermatitis. The skin disease most frequently
seen in both the general practitioner’s office and that of
the dermatologist is contact dermatitis, which accounts
for more loss of time from work than any other skin
disease.

An explanation of the term may be helpful. In this
form of dermatitis the sensitive individual coming in
contact with a certain substance breaks out with a skin
eruption at the site of contact, and the condition may
spread to other parts of the body. By definition the sub-
stance must be one that causes no irritation in the aver-
age person. Thus irritation from contact with sulphuric
acid, which is irritating to all, should be called a chem-
ical burn and not contact dermatitis.

Contact dermatitis usually appears first on the exposed
parts of the body likely to come in contact with the
offending substance: the hands, face, and neck, and in
the male the genitals, to which the patient carries the
offending substance with his hands when he urinates.

The clinical picture of acute contact dermatitis is that
of redness, swelling, a papular and vesicular eruption,
frequently with oozing of a clear, serous fluid, at times
profuse. The affected area is at times fairly well, at other
times poorly demarcated from the normal skin and grad-
ually fades into it. The affected part is hot to the touch,
and the patient suffers from a burning and itching sensa-
tion that may be extremely annoying. If there is per-
sistent contact with the irritating substance and the con-
dition becomes chronic, the redness and swelling will be
less pronounced, but there will be a greater tendency to
thickening of the skin, dryness, and cracking, and the
itching will be a more pronounced feature.

For practical purposes one may classify contact derma-
titis into three categories, according to source of origin:
that acquired in industry or other occupation, that from
clothing, and that from cosmetics.

Though this is not the rule, in some instances the con-
tact dermatitis acquired in the performance of occupa-
tional duties may appear after the individual has worked
on the same job for many years and suddenly acquires
a sensitivity to the materials with which he works. Some
of these occupations and the substances that may
cause irritation in those who follow them are: brick-

layers, lime and concrete; bakers, flour; nurses and doc-
tors, bichloride of mercury and formaldehyde; gardeners,
primroses or other flowers and tomatoes or other vege-
tables; printers, newsprint; painters, turpentine and paint
thinners; fur workers, fur dyes; farmers, weed pollen;
munition workers, workers in chemical plants, or workers
in plants producing or utilizing plastics, and workers in
petroleum industry — all subject to innumerable chem-
ical substances likely to cause trouble; housewives, soap,
ammonia, floor wax, and other household substances; and
carpenters, domestic and tropical woods.

Another group of contact dermatitis affections are
caused by clothing. Shoe leather may cause trouble,
owing to the tanning of the leather or the shoe dye or
polish used. Leather hat bands may produce a derma-
titis of the forehead; the industrial processes used in
making felt hats may also cause trouble. The substances
used in finishing underwear to give it eye appeal on the
merchandise counter may also cause trouble when the
underwear is worn before it is laundered. Dye in gar-
ments, especially in black-dyed furs, may produce a der-
matitis, and many women experience trouble from the
substances used when they dye materials. The material
in nickel wrist watches, leather or plastic wrist watch
bands, metal and rubber suspenders and garters, and
nylon hosiery may also produce a dermatitis in some
persons.

Cosmetics are another source of contact dermatitis.
The most common offender is probably nail polish. It is
noteworthy, however, that the dermatitis is found not
on the hands or around the nails but on parts of the
body touched with the fingers, especially the face, neck,

January, 1946

and eyelids. In particular cases powder, creams, lotions,
perfume, soaps, and deodorants cause trouble. Mascara
and Hair dyes are especially likely to cause dermatitis.

The patch test is a valuable procedure in diagnosing
contact dermatitis. The general practitioner, however,
will seldom have the time, patience, or equipment needed
to perform patch tests with the many substances that
might be causing the trouble in industrial contact der-
matitis. When the source is likely to be clothing or
cosmetics the procedure is a simple one. A bit of the
suspected substance should be placed on the skin, pos-
sibly moistened, then covered with a piece of paper and
fastened to the skin with overlapping pieces of tape.
After it has been in place 48 hours the site should be
inspected. A definitely positive test will show a reaction
similar to the original dermatitis. An unaffected place,
such as the thigh, should be selected for the patch test,
and one must not be misled by the irritation on the skin
caused by the tape.

To treat contact dermatitis successfully one should
elicit and eliminate the cause if possible. To treat acute
contact dermatitis it is necessary to avoid in the begin-
ning any strong or irritating remedies, such as tar medi-
cation. Otherwise one adds insult to injury and only

increases the distress of the patient and prolongs the
disability.

In the acute phase cold wet packs with 3 per cent
boric acid solution or a weak aluminum acetate solution
are imperative. The packs must be cold, must be changed
as soon as they become warm, and must be applied for
many hours each day. If the patient is hospitalized the
packs should be made all day long. A mild, soothing
salve, such as cold cream, boric acid ointment, or a cala-
mine liniment-type emulsion should be applied when the
packs are not applied. When no oozing is present a cala-
mine lotion, possibly with a very small amount of phenol
or menthol, may be used to advantage. Soap and water
are strictly forbidden. The affected parts should be
cleaned with a bland vegetable oil. Oatmeal baths are
soothing and comforting when the dermatitis is exten-
sive. Mild sedation is often necessary.

It is important to know that a patient who has recov-
ered from a contact dermatitis does not acquire im-
munity but will probably suffer a recurrence when he
comes into contact again with the offending substance.
Consequently a person who has acquired a sensitivity to
one of the substances he works with should be shifted to
a different job where he will not be exposed to the
offending substance.

FACTS ABOUT THE PROPOSED HEART HOSPITAL
OF THE NORTHWEST

The Variety Club of the Northwest, sponsor of the proposed Heart Hospital to be
erected on the medical campus of the University of Minnesota, calls the hospital its crowning
achievement of eighteen years devoted to humanitarian endeavors.

In a brochure announcing plans for the new hospital, the Variety Club states that the
building will be a $325,000 structure on a site overlooking the Mississippi River, in a situation
ideal for the treatment and rehabilitation of rheumatic fever patients.

Facilities will comprise a 100-bed hospital, completely equipped with the most modern
accommodations and equipment. The institution will also include a clinic where doctors
throughout the Northwest can study this disease, as well as an out-patient department in which
ambulatory patients from this area can be examined and obtain diagnoses.

The staff will include specialists in heart disease and related diseases. The research facili-
ties at the University of Minnesota will provide cooperation in all phases of medical science.
In the heart hospital it will be possible to study not only rheumatic fever in children but also
all phases of cardiac disease in adults.

The Journal Lancet

Book Reviews

Physical Chemistry of Cells and Tissues, by Rudolph

Hober, with the collaboration of David I. Hitchcock, J. B.

Bateman, David R. Goddard, and Wallace O. Fenn.

Philadelphia: The Blakiston Company, 1945. Pp. 676;

70 figures. $9.00.

Hober has, in a sense, lived through the development of the
subject matter of this book, the application of physical chem-
istry to biological problems. As early as 1902, only a decade
or so after Van’t Hoff and Arrhenius elucidated the properties
of dilute solutions, Hober published a book in German entitled
Physical Chemistry of Cells and Tissues, which subsequently
went through six editions, the last one in 1926. Dismissed as
president of the University of Kiel because of his anti-Nazism,
he has, since 1934, published many original papers as a mem-
ber of the Department of Physiology at the University of
Pennsylvania. For over forty years, therefore, the editor and
main contributor to the volume under review has been an active
teacher and major investigator in his chosen field.

This volume, although it has the same title and much in
common with the German tome, is not a translation of the
latter. The tremendous advances made since 1926 have necessi-
tated an entirely new book, to which others have contributed
sections. It begins with a review of certain selected principles
of physical chemistry and a discussion of the properties of large
molecules. The subjects of permeability and the influence of
some extracellular factors on cell activity are then taken up.
The remainder of the book is devoted to the two most im-
portant general questions of physiology: (1) The energy re-
leasing mechanisms of the cells, and (2) the application of the
released energy to the performance of work, mainly mechanical
work by contractile tissues, and chemical work (secretion, ab-
sorption, and osmoregulation) by living membranes. Written
on a graduate level, this volume by Hober and his collaborators
will be useful mainly to advanced students, investigators, and
specialists. To these it should prove exceedingly, and probably
uniquely, valuable both as a reference work and as an introduc-
tion to the important problems in certain fields. But there are
few readers with biological interests who will not find it stimu-
lating, informative, and rewarding.

In some instances there is room for disagreement with con-
clusions arbitrarily stated; in others, the essential reasoning in-
volved in reaching conclusions from experimental data is omit-
ted. Moreover, clearer presentations of certain of the topics are
available elsewhere. However, such faults are in large part
inevitable and certainly not to be overemphasized in relationship
to the positive virtues of the book as a whole.

General and Plastic Surgery, with Emphasis on War
Injuries, by J. Eastman Sheehan, M.D. New York and
London: Paul B Hoeber, Inc., 1945. 356 pages, 856 illus-
trations. Price, $6.75.

This book is not a complete treatise in any sense of the
word. Those portions of it which deal with the problems of
war surgery, despite their timeliness, probably detract from the
value of the book. The author has made no attempt to treat
the subject matter in a critical manner. The author’s opinions
concerning a wide variety of subjects do not conform at all to
those opinions held by surgeons treating combat casualties in
the Mediterranean and European theaters of war. The greater
portion of the book is replete with obsolete or unorthodox ideas
and phrases, vague in meaning, such as, "septicaemia of the
colon,” "denser muscles,” etc.

To the reviewer it seems misleading to state that "In our
armed forces each man’s blood type is determined in advance
and recorded on his identification tag. Thus transfusion is
possible without the preliminary delay necessary in typing.”
Actually it was recognized early in the war that the blood
group designated on the identification tag could not be de-
pended upon and that preliminary typing was necessary if
many serious transfusion reactions were to be avoided.

The statement is made in the section dealing with wound
excision that "local anesthesia is preferable.” This is absolutely
contrary to the policy followed in the Mediterranean Theater,
where it was found that local anesthesia was rarely if ever
adequate for debridement or wound excision. It is also stated
in a discussion of the dressing of excised wounds that "vase-
line gauze, closely but lightly applied, gives good tissue sup-
port.” This statement may be true. The reviewer does not
know what "tissue support” means, but as a dressing applied
to freshly excised wounds vaseline gauze has proved much in-
ferior to plain fine mesh gauze.

In a discussion of anesthesia for chest wounds the following
remarkable statements are made: "If inhalation anesthesia

must be used because of the patient’s resistance to other anes-
thetics irritating vapors that stimulate respiratory activity must
be avoided. Intubation must also be avoided since the air pass-
age must be kept free at all times.” It is to be regretted that
books proposing to cover the problems of war surgery should be
written by men whose experience with this phase of surgery
has been, to say the least, inadequate.

Those chapters of the book which deal with plastic surgery
are much better written and of some real value. They com-
prise about one-third of the total content of the book. The 856
illustrations, of which the majority are pen and ink drawings,
are well executed.

The Herbal of Rufinus. Edited from the Unique Manu-
script by Lynn Thorndyke, assisted by Francis S. Ben-
jamin, Jr. Chicago: University of Chicago Press, 1945.

Pp. xliii -fi 476. $5.00.

This handsomely produced and scholarly volume makes avail-
able the text (in Latin) of De virtutibus herbarum, by Ru-
finus, called "the forgotten botanist of the thirteenth century.”
It was transcribed from a rotograph of the unique manuscript
in the Laurentian Library at Florence received by the Columbia
University Library just before Italy entered the war.

Rufinus, a monk and teacher who "pursued the seven liberal
arts in the cities of Naples and Bologna,” is distinguished
among mediaeval herbalists for his accurate and extensive ob-
servations of plant life. The cultural background of the botany
and materia medica of the authorities he cites is predominantly
oriental, but the foreground, including his own additions, is
of his own time and environment.

Essentials of Allergy, by Leo H. Criep, M.D. Philadelphia:
J B. Lippincott Co., 381 pages, 1945, price $5.00.

This small manual, a complete book on allergy, is divided
into seventeen chapters. The first three discuss clearly hyper-
sensitiveness, anaphylaxis and the mechanism of allergy. The
remainder are devoted to the usual allergic diseases and in-
clude one on allergy in children and another on diagnostic cu-
taneous tests. Subject matter is arranged to appeal to medical
students. Case histories illustrate most of the allergic diseases
which are discussed. At the end of each chapter there is a
short summary and bibliography. This feature is of special
usefulness to the doctor who is beginning to take an interest in
allergy.

The author has made a special effort to eliminate all contro-
versial material and to present only the approved procedures of
diagnosis and treatment.

Sex Endocrinology: A Handbook for the Medical and
Allied Professions. Bloomfield, New Jersey: Schering Cor-
poration, 1944. Pp. 88, index, illustrations.

This attractive handbook summarizes what is known at pres-
ent about sex endocrinology. After an introductory chapter on
endocrinology, the subjects discussed include chemistry of the
sex hormones, history of sex endocrinology, sex function and
anatomy, control of the sex hormones, the sex estrogenic hor-
mone, estrogenic hormone therapy, the corpus luteum hormone,
corpus luteum hormone therapy, the male sex hormone, male
sex hormone therapy, the gonadotropins, and gonadotropic hor-
mone therapy.

The handbook is available to physicians without charge from
the publishers.

Serves the Medical Profession of

MINNESOTA, NORTH DAKOTA, T SOUTH DAKOTA and MONTANA

Official Journal of the American Student Health Assn., Great Northern Railway Surgeons’ Assn., Minneapolis Academy of Medi-
cine, Montana State Medical Assn., North Dakota Society of Obstetrics and Gynecology, North Dakota State Medical Assn.,
Northwestern Pediatric Society, Sioux Valley Medical Assn., South Dakota Public Health Assn., South Dakota State Medical Assn.

North Dakota State Medical Assn.

Dr. James F. Hanna, Pres.

Dr. A. E. Spear, Pres.-Elect
Dr. L. W. Larson, Secy.

Dr. W. W. Wood, Treas.

North Dakota Society of
Obstetrics and Gynecology
Dr. E. H. Boerth, Pres.

Dr. Paul Freise, Vice Pres.

Dr. G. Wilson Hunter, Secy .-Treas.

Minneapolis Academy of Medicine
Dr. Ernest R. Anderson, Pres.

Dr. Jay C. Davis, Vice Pres.

Dr. Cyrus O. Hansen, Secy.

Dr. Thomas J. Kinsella, Treas.

ADVISORY COUNCIL

South Dakota State Medical Assn.
Dr. William Duncan, Pres.

Dr. F. W. Howe, Pres.-Elect
Dr. H. R. Brown, Vice Pres.

Dr. Roland G. Mayer, Secy. -Treas.

South Dakota Public Health Assn.
Dr. J. M. Butler, Pres.

Dr. C. E. Sherwood, Vice Pres.

Dr. Gilbert Cottam, Secy.-T reas.

Sioux Valley Medical Assn.

Dr. D. S. Baughman, Pres.

Dr. Will Donahoe, Vice Pres.

Dr. R. H. McBride, Secy.

Dr. Frank Winkler, Treas.

Montana State Medical Assn.

Dr. S. A. Cooney, Pres.

Dr. M. A. Shillington, Pres.-Elect
Dr. R. F. Peterson, Secy.-T reas.

Northwestern Pediatric Society
Dr. G. B. Logan, Pres.

Dr. Geo. Kimmel, Vice Pres.

Dr. Northrop Beach, Secy. -Treas.

Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.

Dr. R. C. Webb, Secy .-Treas.

American Student Health Assn.

Dr. Ralph I. Canuteson, Pres.

Dr. Glenadine Snow, Vice Pres.

Dr. G. T. Blydenburgh, Secy. -Treas.

Dr J . O. Arnson
Dr. D. S. Baughman
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. A. R. Foss

Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. I . Mabee
Dr. J. C. McKinley

BOARD OF EDITORS

Dr. J. A. Myers, Chairman

Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C. H. Nelson
Dr. N. J . Nessa
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. C. E. Sherwood
Dr. M. A. Shillington

Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J. H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. C. A. Stewart
Dr. S. E. Sweitzer

Dr. W. H. Thompson
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin,
Secretary

LANCET PUBLISHING CO., Publishers, 84 South Tenth Street, Minneapolis 2, Minnesota

Minneapolis, Minnesota, January, 1946

THE MEDICAL OUTLOOK IN THE
NEW YEAR

During the recent war the medical profession and its
allies made a demonstration in disease control and the
saving of lives among the physically injured which far
exceeded that of all previous time. The efficaciousness of
the various immunizing agents was again clearly dis-
played. Chemotherapeutic agents such as the sulfona-
mides, sulfones, and antibiotics, particularly penicillin
and streptomycin, were developed and used so effectively
that for all time the past decade will be regarded as one
of the most important eras in the advancement of chemo-
therapy. Standard surgical techniques, together with
those developed during the war, combined with new spe-
cific drugs, saved the lives of large numbers who, at any
earlier time, would have died.

Likewise at home advances were made in maintaining
and improving the health of the civilian population.

Scientists, public health workers, nurses, and physicians
everywhere, although handicapped by limited numbers,
worked diligently. Many long since retired returned to
active practice. Serious epidemics were prevented; sur-
gery and chemotherapy advanced to the benefit of thou-
sands. Even tuberculosis mortality, which had increased
in every previous war and markedly increased in most
of the nations during the recent war, actually decreased
annually in the United States, reaching the all time low
rate of approximately 38 per 100,000 in 1945. Every-
where one heard expressions of sympathy for the over-
worked physicians. We who stayed at home deserved no
sympathy or special praise — strenuous work at home is
not a sacrifice; it is a privilege. Those who left their
homes and subjected themselves to the hazards of war-
fare deserve sympathy and praise which can never be
expressed in any manner in proportion to the sacrifices
they made and the service they rendered.

The Journal Lancet

Despite all that was accomplished during the war,
some medical problems were increased or created. Many
contracted malaria and are returning to areas where it
was not previously endemic. In some of these areas the
potential vection exists; therefore, to prevent spread of
the disease great care must be exercised in mosquito
control. Many in military service overseas became in-
fected and reinfected with tubercle bacilli. In most of
them the disease has not had time to mature to "signifi-
cant” clinical proportions. Nevertheless, many of these
infections will be reflected in morbidity and mortality
within the next few decades. Other diseases which have
been extremely rare in this country, such as tsutsuga-
mushi, paragonimiasis, and schistosomiasis, have been
contracted by members of our service forces abroad.

Many physicians have returned from military service,
and it is anticipated that the majority will soon be dis-
charged, so in 1946 we can unite in solving the problems
created by the war and resume our combined efforts
against the destroyers of health and life. To achieve
continued success we are better equipped than at any
time in the history of our profession.

J.A.M.

A.M.A. HOUSE OF DELEGATES MEETING

At the A.M.A. House of Delegates session held in
Chicago recently the standpatters suffered considerable
defeat at the hands of the progressives. The waiting,
drifting policy of the past few years was superseded by
one of aggressive action. This change is best illustrated
by the fact that the house instructed the Board of Trus-
tees and the Council on Medical Service and Public Re-
lations, without a dissenting vote, to develop immediately
"a specific national health program with emphasis upon
the nation-wide organization of locally administered pre-
payment plans.” In the past the house has repeatedly
deplored the sad state of public relations for medicine
but has done little about it. Now the Board of Trustees
is to engage an expert consultant to examine this entire
field, with a more constructive policy in mind for the
future. Indicating that they will brook no delay, the
House of Delegates will hold two sessions annually. The
house voiced the opinion that there is need of developing
among the young men of the profession an interest in
serving medical organizations — an opinion in keeping
with the trend of the times. We already have this trend
manifested in the existence of junior chambers of com-
merce, junior republican clubs, and some medical societies
limiting their membership to young men. And so "the
old order changeth, yielding place to new . . . lest one
good custom should corrupt the world.” We believe that
liberal youth and conservative age will find a harmonious
solution of the whole problem.

A. E.H.

We make the third part of medicine regard the pro-
longation of life: this is a new part, and deficient,
though the most noble of all. — Francis Bacon, Novum
Organum.

ANNOUNCEMENTS

American College of Physicians Resumes
Annual Meetings

The American College of Physicians will resume its
annual meetings in 1946. The 1946 meeting will be held
in Philadelphia, May 13-17 inclusive, with headquarters
at the Philadelphia Municipal Auditorium, 34th Street
below Spruce. The meeting will be conducted under the
presidency of Dr. Ernest E. Irons, Chicago, and the gen-
eral chairmanship of Dr. George Morris Piersol, Phila-
delphia. Other medical groups are urged to plan their
meetings at times that will not conflict with that of the
College.

Directory of Approved Surgical Training Plans
Published by American College of Surgeons

Chiefly as an aid to medical officers returning from
war duty, the American College of Surgeons, 40 East
Erie Street, Chicago, has published a directory listing
and describing the approved programs of graduate train-
ing in surgery in 240 civilian hospitals in the United
States and Canada and in 32 Naval, 7 Veterans Admin-
istration, and 10 U. S. Public Health Service hospitals.
The total number of approved training plans in the 289
hospitals is 228 in general surgery and 522 in the sur-
gical specialties. Approximately 2000 surgeons may be
trained in these 750 training plans in 289 hospitals, while
the College points out that training facilities for at least
5000 are urgently needed for returning medical veterans
whose training in surgery was interrupted by their mili-
tary service. Publication of the directory is expected to
stimulate the formation of additional programs of train-
ing in suitable hospitals.

1946 Examinations, American Board of
Ophthalmology

The 1946 examinations of the American Board of
Ophthalmology will be held in Chicago, January 18-22;
New York in April, probably 10th through 13th; San
Francisco, June 22-25; and Chicago, October 9-12. The
examination originally scheduled for Los Angeles, Jan-
uary 28-31, has been cancelled, owing to transportation
difficulties. The San Francisco examination has been
substituted. Officers for 1946 are: Chairman, Edward C.
Ellett, Memphis; Vice Chairman, Georgiana D. Theo-
bald, Oak Park, Illinois; Secretary Treasurer, S. Judd
Beach, Portland; Assistant Secretary, Theodore L. Terry,
Boston; Consultant, Walter B. Lancaster, Boston.

A new ruling requires that previously accepted candi-
dates mail their lists of surgery to the Board office at
least 60 days prior to examination. New applicants are
now required to send their lists with application.

Graduate Course in Ophthalmology

The sixth annual spring postgraduate course in oph-
thalmology and otolaryngology will be held in Portland,
Oregon, April 15-20, 1946. Guest speakers will be Dr.
Algernon B. Reese of Columbia University and Dr.
Gabriel Tucker of the University of Pennsylvania Grad-
uate School. The program will include lectures, clinical
demonstrations, and ward rounds. Further information
may be secured from the secretary, Dr. Harold M.
U’Ren, 624 Medical Arts Building, Portland 5.

January, 1946

. . . fUEET OUR COflTRIBUTORS . . .

Dr. Rae Thornton La Vake, who has practised in Minne-
apolis since 1912, is a graduate of Yale University (B. A. ,1905)
and of the College of Physicians and Surgeons, Columbia Uni-
versity (M.D.,1909), with graduate work in New York hospi-
tals (1909-12). He is assistant clinical professor of obstetrics
and gynecology at the University of Minnesota, and a member
of many societies, including the American Association of Ob-
stetricians, Gynecologists, and Abdominal Surgeons, the Ameri-
can College of Surgeons, the A M. A., and the Minnesota
Academy of Medicine. Dr. La Vake first contributed to the
Journal Lancet in 1913.

Melvin Elwood Koons of Grand Forks, North Dakota, has
been with the North Dakota State Health Department for
twelve years and associate professor of public health at the
University of North Dakota since 1942. He is a graduate of
the University of Maryland (B.S.,1930), and holds the degree
of M.Sc. from Pennsylvania State College and the degree of
M.P.H. from the Johns Hopkins School of Hygiene and Pub-
lic Health (1939). He is a graduate of the course in tropical
and military medicine given by the Army Medical School (De-
cember 1943). He is secretary-treasurer of the State and Pro-
vincial Public Health Laboratory Directors’ Conference, a Fel-
low of the American Public Health Association, and a member
of the Society of American Bacteriologists, the A. A. A S., and
the North Dakota Academy of Science.

Dr. John Milton Butler of Hot Springs, South Dakota,
has practised in that city for ten years. A graduate of Nebras-
ka Wesleyan, he had his medical training at the University of
Nebraska College of Medicine (B.S.M., M.D., 1934) , and fol-
lowing his graduation held a preceptorship in orthopedic sur-
gery. His specialty is general and orthopedic surgery. He is
chief of staff of Lutheran Hospital, Hot Springs, consultant in
surgery for the Veterans Administration, and orthopedist to
the State Crippled Children. A past president of the South
Dakota Public Health Association, he is a member of the
A.M.A., the Black Hills District Medical Society, and the
South Dakota State Medical Society.

Dr. Herbert C. Leiter of Sioux City, Iowa, has practised
in that city for five years. A graduate of the medical school of
the University of Graz (Austria) , Dr. Leiter did graduate work
at the Clinic of Syphilology and Dermatology, University of
Vienna. He is a member of the Society of Investigative Der-
matology of the College of Allergists.

MEDICAL CONTINUATION COURSES AT
UNIVERSITY OF MINNESOTA
Winter and Spring 1946

The University of Minnesota Center for Continuation
Study announces a series of courses for graduates in
medicine whose plans for continuation education were
interrupted by military service. The generous financial
assistance of the W. K. Kellogg Foundation, Battle
Creek, Michigan, has made this program possible.

The courses of study have been arranged for physi-
cians who plan to (I) accept an association with a spe-
cialist, (2) obtain a residency, (3) prepare for American
Board examinations, or (4) return to practice.

Headquarters for the continuation courses will be the
Center for Continuation Study, located near 17th Avenue
S.E. and University Avenue on the Main Campus, Uni-
: versity of Minnesota. The Center contains a parking
garage, registration desk, administration offices, class-
rooms, commons, chapel, dining hall, and living rooms.
Erected in 1937, it is used for the continuation education
of professional graduates; it is said to be the only insti-
tution of its kind in the United States.

Classes will be taught at the Center for Continuation
Study, Medical School, University of Minnesota Hos-
pitals, Minneapolis General Hospital, Ancker Hospital,
St. Paul, and affiliated teaching institutions.

Faculty will consist of representatives from the facul-
ties of the Medical School, other University depart-
ments, and the Mayo Foundation, Rochester; in addition,
teachers from other medical centers will participate.

Registration for less than one quarter will not be ac-
cepted. Each course will occupy the full time of the
registrant. A certificate of attendance will be issued after
the completion of each quarter; a statement indicating
the subjects studied and a mark of satisfactory or unsatis-
factory will be given. Students whose study or attend-
ance record is unsatisfactory will be asked to withdraw.

Successful applicants will report January 4, 1946 at
9 a.m. to complete their registration and to meet with
their advisers. Representatives of the Veterans Adminis-
tration will be present to explain existing regulations. In
addition there will be discussions on recent developments
in medicine, hospital service, and social welfare. Orienta-
tion session closes January 5, noon. Classes start Mon-
day, January 7, 1946.

PROGRAM

1. Continuation Course in Medicine, January 4 to March
30, 1946. Subjects: Infectious Diseases; Diseases of Respira-
tory Tract, Blood, Blood-forming Organs, Liver, Gallbladder,
Pancreas, Skin, Heart, Arteries, Veins, Kidney, Endocrine
Glands, Metabolism, Osseous System, Central Nervous System,
and Diseases Peculiar to Childhood. Lectures and conferences,
Monday through Saturday, 8:30 a.m. to 12:30 p.m. Ward
walks, clinics, demonstrations, Monday, Wednesday, Friday,
2:30 to 4:30 p.m. Elective periods Tuesday, Thursday, and
Saturday afternoons. Tuition $150 and incidentals. Registra-
tion limited.

2. Continuation Course in Surgery, April 8 to June 29,
1946. Subjects: Diseases of the Gastrointestinal Tract (Upper),
Colon and Rectum, Bones, Joints, Muscles, Chest, Urogenital
Tract, Eye, Ear, Nose, Throat, Nervous System, Female Geni-
talia. Obstetrics; Anesthesiology; and Physical Medicine. Lec-
tures, conferences, and colloquia, Monday through Saturday,
8:30 a.m. to 12:30 p.m. Ward walks, clinics, demonstrations,
Monday, Wednesday, Friday, 2:30 to 4:30 p.m. Elective periods
Tuesday, Thursday, and Saturday afternoons. Tuition $150
and incidentals. Registration limited. Note: Physicians enroll-
ing for the first time will report for registration and orienta-
tion April 5 and 6, 1946.

3. Continuation Course in Basic Sciences, January 4 to
March 30, 1946. Subjects: Anatomy, Pathology, Physiology,
Physiological Chemistry, Bacteriology, Immunology, and Phar-
macology. Physicians will also attend departmental exercises in
specialty they wish to study: the various clinical departments
will be represented by advisers. Tuition $150 and incidentals.

4. Continuation Courses in Basic Sciences (concluded),
April 8 to June 29, 1946. Tuition $150 and incidentals.

5. Continuation Course in Pathology of Diseases of
the Skin, January 21 to February 20, 1946. Arranged for
dermatologists, residents in dermatology, and physicians who
plan to take a residency in dermatology or an association with
a dermatologist. Tuition $50 and incidentals.

6. Continuation Course in Otolaryngology, January 14
to 18, 1946. Arranged for otolaryngologists, residents in oto-
laryngology, and physicians who plan to take a residency in
otolaryngology or an association with an otolaryngologist. Tui-
tion $25 and incidentals. Registration limited.

7. Continuation Course in Hospital Administration,
January 21 to 25, 1946. For hospital administrators, assistant
hospital administrators, graduate students in hospital adminis-
tration, and physicians and others who plan to take a course in
hospital administration. Tuition $15 and incidentals.

The Journal Lancet

Views lUtns

The Office of the Surgeon General announces that by
January 1 more than 14,000 doctors will have been re-
turned to civilian life, which is more than a third of the
total number comprising the Army Medical Corps at its
peak. By June 1946 it is expected that all but 11,000
doctors will be released. Meanwhile, news of Northwest
doctors resuming practice after medical service with the
armed forces in all theaters of World War II, some-
times for five years or more, continues to come into the
Journal Lancet office at a rate that precludes indi-
vidual notice.

The Black Hills (Ninth) District Medical Society
met at Deadwood, South Dakota, on November 29,
1945, with 22 present. Capt. Dalton M. Welty spoke
on "The Unstable Colon," Col. Peter A. Peffer and
associates of Fort Meade Veterans’ Facility on "Neuro-
psychiatric Problems,” and Dr. W. E. Olson on Electro-
shock Convulsion Therapy.” Newly elected officers are
Dr. W. A. Dawley, Rapid City, President; Dr. N.
Wells Stewart, Lead, Vice President; Dr. H. E. David-
son, Lead, who expects to return to private practice in
January, Secretary-Treasurer, succeeding Dr. Stewart,
who becomes Vice President.

The Yankton District Medical Society met December
13 at Yankton, South Dakota, with 25 present, to hear
Dr. R. N. Larimer of Sioux City, Iowa, speak on "The
Treatment of Congestive Heart Failure,” and case re-
ports by Dr. George E. Johnson of Yankton. Newly
elected officers are Dr. A. P. Reding, Marion, President;
Dr. V. I. Lacey, Yankton, Vice President; and Dr. J. A.
Hohf, who continues as Secretary-Treasurer. Dr. George
E. Johnson, Dr. F. W. Haas, and Dr. F. J. Abts were
elected censors.

Dr. J. Arthur Myers, Chairman of the Board of
Editors of Journal Lancet, has been elected Editor-
in-Chief of the Journal of the American College of
Chest Physicians.

Dr. A. F. Branton of Willmar, Minnesota, has left
for Chattanooga, Tennessee, where he will be superin-
tendent of the Baroness Erlanger Hospital.

News from the University of Minnesota Medical
School: The Ebin Foundation of Minneapolis has made
a gift of $25,000 to the school in support of five grad-
uate medical fellowships of $1,000 a year each, to be
awarded to veterans of World War II. The Medical
School has set up a statement of conditions for the affilia-
tion of hospitals with the school for the purpose of grad-
uate training in the clinical specialties. An electron mi-
croscope, to be used in such investigations as intracellular
identification of the agent responsible for the high per-
centage of mammary carcinoma in susceptible strains of
mice, microscopic examination of bone, dentin, and
enamel, and studies of the finer details of bacteria, has
been set up in Millard Hall. News of the program of
postgraduate courses offered to veterans will be found
elsewhere in this issue.

Dr. Wesley W. Spink of the University of Minne-
sota Medical School gave the first annual Newton Evans
Lecture in Bacteriology and Pathology at the College of
Medical Evangelists, November 29, on "Brucellosis:
Diagnostic and Therapeutic Considerations.” Dr. Robert

G. Green will present a lecture on "Health and Disease
in Wildlife as Exemplified by Tularemia,” before the
Yale Medical Society on January 9, and will also con-
duct several seminars during his three-day visit.

Dr. Hart E. Van Riper, pediatrician, formerly of
Madison, Wisconsin, has been appointed assistant med-
ical director of the National Foundation for Infantile
Paralysis. As assistant to Dr. Don W. Gudakunst, med-
ical director, Dr. Van Riper will supervise the founda-
tion’s program of medical care and treatment for infan-
tile paralysis patients throughout the United States.

The American Red Cross has appointed an Advisory
Board on Health Services to coordinate activities in the
health field. Dr. Gaylord W. Anderson and Dr. Harold
S. Diehl, both of Minneapolis, and Dr. Henry Helm-
holz, Rochester, are among those appointed.

February 6, 1946, has been set as the date for National
Social Hygiene Day. The American Social Hygiene
Association, 1790 Broadway, New York 19, sponsor of
the day, urges local social hygiene associations, medical
societies, health departments, and other community
agencies to cooperate in a meeting that will mark a mile-
post in a united drive toward the major objective of the
social hygiene program: the protection of the family
from the perils growing out of the venereal diseases,
prostitution, and the failure to give young people wise
guidance in meeting their sex problems.

Three major appointments to the staff of the North
Dakota State Department of Health have been an-
nounced by Dr. G. F. Campana. Lt. Col. Lloyd K.
Clark has returned to his former position as director of
the Division of Sanitary Engineering, replacing Jerome

H. Svore, senior sanitary engineer, who has been acting
director. Dr. William H. Smith, who has been acting
director of the Division of Preventable Diseases, was
named director. Dr. Robert H. Kling will be tubercu-
losis consultant in this division.

At a farewell program for Dr. B. A. Bobb of
Mitchell, South Dakota, whose retirement after more
than fifty years as practicing physician and surgeon was
noted in our November issue, Dr. F. D. Gillis estimated
that Dr. Bobb had treated some 1,825,000 patients in
his many years of practice. Dr. Gillis, one of four doc-
tors who spoke in tribute to Dr. Bobb, said that the vet-
eran physician had probably performed some 55,000
operations, delivered 6250 babies, set 6000 broken bones,
and given some two million dollars worth of charity
service. Dr. O. J. Mabee, in charge of the program, Dr.
Edward Bobb, and Dr. J. H. Lloyd also spoke. A fare-
well dinner honoring Dr. and Mrs. Bobb, who will make
their home in California, was given on November 21,
1945.

Dr. C. L. Wendt of Canton, South Dakota, cele-
brated the fiftieth anniversary of his practice of medicine
there in November, 1945, with a dinner at his home for
members of the Athenian Debating Society.

January, 1946

Dr. Cecil J. Watson spoke on "Hepatitis” before the
Minnesota Pathological Society December 18, 1945, at
the Medical Science Amphitheater, University of Min-
nesota.

Dr. Oscar Harvey has become director of the com-
bined City of Sioux Falls and Minnehaha County health
departments at Sioux Falls, succeeding Dr. Robert M.
Ferguson.

Dr. Gilbert Cottam, superintendent of the South Da-
kota State Board of Health and a member of the
Journal Lancet Board of Editors, has returned to his
office after attending a meeting of the House of Dele-
gates of the A.M.A. and the meeting of the Western
Surgical Association, in Chicago.

A survey conducted by the social studies committee of
the American Association of University Women found
health conditions and the public health set-up in Grand
Forks and Cass counties to be the best in the State of
North Dakota. The doctors, nurses, and welfare work-
ers interviewed in the survey all favored setting up a
full-time county public health unit in Grand Forks.

The North Dakota Physicians Service of Fargo, first
nonprofit medical corporation organized under a 1945
enabling act, has named Dr. O. A. Sedlack as president,
Dr. F. I. Darrow, vice president, and Dr. W. E. G.
Lancaster, secretary-treasurer.

Dr. Carl William Hammer has been named physician
in charge of the Student Health Service at Montana
State College, Great Falls. Dr. Hammer, released from
the Army Medical Corps in August, 1945, formerly
practised in Oxford, Michigan.

The first cooperative hospital and health center to be
organized in a rural Minnesota community has been in-
corporated under the name "Pelican Valley Health
Center.” It will serve Pelican Rapids and surrounding
communities.

The services of A. G. Stasel, superintendent of Eitel
Hospital and manager of Nicollet Clinic, Minneapolis,
are in demand as an organizer of detailed health surveys
of communities that want to establish hospitals. Social,
economic, and medical factors are included in the survey,
on the basis of which Stasel advises the community com-
mittee on the size of hospital desirable for their needs.

Dr. Henry A. Sincock of Superior has been elected
president of the Interurban Academy of Medicine, whose
membership is made up of physicians of the Twin Ports,
Duluth and Superior.

The Sixth District Medical Society met December 11,
1945, in Bismarck, North Dakota, to hear reports from
medical officers recently returned to civilian practice from
service with the armed forces. Dr. Ralph Vinje, Beulah,
spoke on "War Experiences in the South Pacific”; Dr.
R- F. Nuessle, Bismarck, on "War Experiences in the
European Theater of War”; Dr. R. B. Radi, Bismarck,
on "Experiences as State Medical Officer of Selective
Service in North Dakota and Minnesota”; and Dr. R.
W. Henderson, Bismarck, on "Army Hospital Experi-
ences in the United States.”

Officers elected for 1946 are Dr. R. B. Radi, Presi-
dent; Dr. C. J. Baumgartner, Vice President; Dr. W.
B. Pierce, Secretary-Treasurer; Dr. C. C. Smith, dele-

gate to the state medical association for a three-year
term, with Dr. M. S. Jacobson as alternate; and Dr.
F. F. Griebenow, Censor.

The Cascade County Medical Society, Great Falls,
Montana, met December 21, 1945, for a dinner meeting,
with 18 present. The newly elected officers are Robert
J. Holzberger, President; Thomas Keenan, Vice Presi-
dent; L. L. Maillet, Secretary-Treasurer. Dr. Eugene
Hildebrand was admitted to membership in the society
in November.

Jon M. Jonkel, director of the American Hospital
Association’s public relations department, announces his
resignation effective January 5. He will establish an or-
ganization specializing in the public relations problems
of hospitals, and will offer assistance in the public rela-
tions programs of individual hospitals and as public rela-
tions consultant in fund-raising campaigns.

The Journal Lancet directs attention to the services
offered to physicians through the Family and Children’s
Service, as described in the following letter.

FAMILY AND CHILDREN’S SERVICE

Combining the Services of Children’s Protective Society
and Family Welfare Association

214 Citizens Aid Building : 404 South 8th Street

Minneapolis 2, Minnesota

To the Physicians and Surgeons of Minneapolis
and Hennepin County:

Physicians are doing double duty today. Not only
is the number of patients increasing, but ill people are
more difficult to treat because of the unrest and ten-
sion under which they live. In recognition of this
many doctors have been using our services to comple-
ment their treatment.

An obstetrician recently referred a young woman
to us. She was pregnant, alone, her husband still in
service and she and the baby would be without hous-
ing when she left the hospital after confinement. Her
original happiness over the pregnancy was fast waning
and she was becoming depressed and ill. When she
found in our counselor a person interested in her, one
with whom she could talk freely and who would help
her work out practical plans, her health, both mental
and physical, improved.

A family was referred to us when the father’s con-
valescence was hampered because he worried over
finances and was afraid his wife couldn’t manage the
home and family alone. The "standing by” of one
of our workers and some temporary financial help
enabled him to return to his job soon, but not too
soon for his own well-being.

Doubtless you are acquainted with our general pur-
pose and services. They include counsel, budgeting,
placement and, in rare cases, relief. Our help is pro-
fessional, courteous, and completely confidential and
you need not hesitate to refer any patient to us.
Either he or you may call for an appointment.

If you care to call us, please feel free to do so
(Main 5275). We want you to know and understand
the kind of help we offer and to use it in the way
that will be most helpful to you.

Sincerely yours,

Clark W. Blackburn, General Secretary,

Family and Children’s Service of Minneapolis
and Hennepin County, a Community Fund
Agency participating in the War Chest.

MEASURING THE COMMUNITY FOR A
HOSPITAL*

There are many considerations which must enter into
any decision to build a hospital: the size of the com-
munity and its tributary population; availability of exist-
ing hospital facilities in nearby communities; the charac-
ter of transportation and transportation routes available;
the sickness rate of the community; the habits of the
community as to utilization of hospital facilities; and the
physicians available for staffing the hospital.

Ratio of Beds to Population. There have been many
studies into the relation between the size of a community
and its hospital need. The studies of the United States
Public Health Service, as a part of the 1935 business
census of the United States, indicate in general that the
actual utilization of beds per 1000 of population in-
creases with the density of population and with the eco-
nomic level of the population.

Ponton’s study of utilization of beds in the United
States indicated an actual utilization of approximately
2.5 beds per 1000 population. The U. S. Public Health
Service estimates indicate a need for about 4.0 beds per
1000 of population on a country-wide basis.

On the other hand, Morrill’s study of the utilization
of beds in the states of Indiana, Illinois, and Wisconsin
for the year 1937 indicated actual bed utilization rates
in cities of 10,000 to 25,000 varied from 11.1 beds per
1000 urban population to 1.54 of urban population and
in cities of 25,000 to 75,000 from 8.6 beds per 1000 of
urban population to 1.02 beds per 1000 of urban popu-
lation. The obvious conclusion from these studies is
that while an overall, country-wide figure may be cor-
rect, it cannot be taken as a suitable figure for any given
community.

Care must always be taken in the interpretation of all
bed figures, since some are based only on the population
of the city in which the hospital is located, while others
are based on the total population in both the city and
its tributary area.

The size of the population tributary to any given town
or city is affected by many variables. The most impor-
tant, of course, is the availability of other hospital facili-
ties within the general area. This involves not only the
size of the neighboring hospital and the completeness of
its equipment and its convenience from a transportation
standpoint, but also the relative regard with which the
physicians on its staff are held in the community.

Another factor which may be of great importance is
what might be called the hospital "consciousness” of the
community. Thus, one community may send five times
as many of its maternity cases to the hospital as another
community does. The latest available statistics, for in-
stance, indicate that in Mississippi 15.8 per cent of all
births occur in hospitals, while in Connecticut 89.4 per
cent of all births occur in hospitals. On a country-wide
basis the percentage of births occurring in hospitals rose
from 33.6 in 1936 to 55.0 in 1941, 67.9 in 1942, and
72.1 in 1943. The total number of births occurring in

^Condensed from "The Individual Hospital," 1945 Hospital
Review. Chicago: American Hospital Association, 1945.

The Journal Lancet

hospitals in the United States increased from 621,896
in 1939 to 1,924,591 in 1943.

In the farm areas and in towns having a large pro-
portion of separate residences, the inclination of the sick
to be treated at home is much greater than it is where
a sizable proportion of the community lives in the more
modern pigeonhole apartment, in which there is no room
to be sick.

It is also necessary to distinguish between the demand
incident to the wartime displacement of populations and
what should be considered the permanent population,
including due allowance for its probable future growth.

Emergency Care. An argument often advanced in
favor of a hospital in every community is that it is neces-
sary to have facilities available for emergency care. This
argument is often given undue weight. The number of
emergencies requiring the full facilities of a hospital is
much smaller than is usually realized. Military experi-
ence demonstrates that beyond the treatment of shock,
the arrest of hemorrhage, and the protection of the
wound, the emergency surgical patient usually fares bet-
ter if he can reach the facilities of a completely equipped
and staffed hospital within six hours than he does if an
attempt at more complete treatment is made where only
meager facilities are available. Civilian application of
this principle means that unless the hospital is large
enough to afford complete facilities and the staff is
qualified to deal fully with major life-threatening emer-
gencies, the average patient would fare better to have
only simple immediate emergency treatment and then be
transported a reasonable distance — 30 to 40 miles in
most cases— to a hospital in which more complete facili-
ties and a more highly skilled staff are available.

Let’s Be Neighborly. It is not unusual to find that
either local pride or the desires or ambitions of some
local group, rather than the welfare of the community
as a whole, determine the organization and construction
of a hospital. A somewhat typical instance of this is seen
in one community in which there are three towns located
at three points of a triangle about 12 miles on a side.
One of these towns with a population of 8000 has a city
owned hospital of 40 beds. Another one with a popula-
tion of 5500 has a voluntary nonprofit hospital of 50
beds, and the third one with a population of 2700 is
now considering the construction of a new hospital to
replace a purely proprietary hospital of 20 beds. From
these three towns it is 40 miles to another city of about
6000 which has two hospitals of 40 and 50 beds respec-
tively. It is about 150 miles to a larger city having a
completely equipped hospital of over 200 beds and a
highly capable staff including all the major specialties.

It is quite evident that this triangular area needs a
good hospital, but it is quite as evident that no one of
the three communities alone is large enough to justify
as large or as well equipp>ed a hospital as the general
community deserves and could staff adequately if all the
facilities for the three cities and their tributary territory
were consolidated into a single institution.

Availability of Professional Staff. It is obviously un-
wise for a community to build and equip a hospital be-

January, 1946

yond the ability of the available physicians to use its
facilities to the best interests of the patients.

It is generally accepted that if the patient is to receive
the best care a certain proportion of it must be by spe-
cialists, and if the hospital is to give adequate care to
its community such specialty care must be available.

There is usually the possibility of calling in specialists
from nearby communities when adequately trained spe-
cialists are not available with the particular community.
The special care of complicated cases is so much a mat-
ter not only of the best facilities but also of skilled team-
work in their use and of continuing careful supervision
that the attending physician may often prefer to transfer
the patient to the specialist rather than bring the spe-
cialist to the patient.

Studies of the need for physicians indicate that there
is definite need for about one physician to 1500 of popu-
lation and that it requires 10,000 or more of population
to furnish sufficient patients to attract and support a
specialist.

Specialist s. The number and type of specialists re-
quired to staff a hospital sufficiently to give relatively
good service to its patients is variable. The three basic
specialties which should always be represented are inter-
nal medicine, surgery, and obstetrics.

The services of the general practitioner are largely in
the field of internal medicine. While it is probable that
a community of 10,000 or so could use the services of a
specialist in internal medicine, or a "diagnostician” as
he is commonly called, to the benefit of its people, it is
probable that it would take a community of two or three
times that size to justify a competent internist in prepar-
ing himself and limiting his practice to this specialty.

It is probable that there is enough surgery in a com-
munity of 10,000 population to justify the services of
a fully qualified surgeon, particularly if the hospital
adheres to the policy described by Dr. Malcolm T. Mac-
Eachern, Associate Director of the American College of
Surgeons:

"The restricting of privileges to do major surgery
to those who are qualified is most essential, and this
protection for the patient is provided in the ap-
proved hospital. The approved hospital has a defi-
nite standard of training, experience, and compe-
tency, and a qualifications committee of the surgical
staff which determines who is and who is not quali-
fied to do major surgery.

"It is a growing custom for hospitals to limit ap-
pointments of heads of departments of the medical
staff to Fellows of the American College of Physi-
cians, Fellows of the American College of Surgeons,
and diplomates of the respective American Boards
for the various specialties. Such a provision assures
a higher quality of clinical work and better super-
vision and control of the professional activities of
the institution. To this end, hospitals are more and
more restricting major surgical privileges to Fellows
of the American College of Surgeons and diplo-
mates of the American Boards for surgery and the

different surgical specialties, or to those of equal

standing as determined by the qualifications com-
mittee.”

The majority of patients enter the hospital to take
advantage of its surgical facilities, and it is therefore
the surgeon who is in most demand.

While the large majority of maternity cases fare well
at the hands of the general practitioner, the fact is that
prospective mothers are becoming so fully aware of the
importance of the best obstetrical skill to their future
well-being that the demand both for hospitalization and
for skilled obstetricians is rapidly increasing. In view of
all the elements entering into the question it is probable
that a community of 15,000 to 20,000 is necessary to
attract and support a fully qualified obstetrician.

Other basic specialties are women’s surgery, children’s
diseases and diseases of the ear, nose, and throat. Wom-
en’s surgery in the small community is usually handled
by either the general surgeon or by the obstetrician.
Children’s diseases can usually be adequately cared for
by the internist. Patients having diseases of the ear,
nose, and throat are usually ambulatory, but are so com-
mon that a community of 15,000 or so will usually be
sufficient to attract and support a qualified specialist.

Experience indicates that one roentgenologist can prop-
erly serve some 60,000 of population and a pathologist
some 100,000. It has been shown that if each individual
hospital is supplied with good technicians, the roentgen-
ologist and the pathologist can serve several small hos-
pitals by working on a "circuit rider” basis.

A community of 20,000 to 25,000 population could
expect to have 18 to 20 active practitioners of whom
three to five would be qualified specialists — an internist,
a surgeon (possibly two) , an ear, nose, and throat spe-
cialist, and an obstetrician. While such a community
could support a hospital of 75 to 100 beds, it would
still be necessary to have some sort of an affiliation with
some larger community for professional service in the
more limited specialties.

Health Centers. Even smaller communities may still
be justified in providing limited facilities for minor and
emergency surgery, normal obstetrics, and the simpler
general medical diseases. It is this type of institution
that is contemplated in the proposed health center which
would at the same time provide clinical laboratory facili-
ties for the practitioners of the community, space for
the community public health agencies, and even, if de-
sired, office accommodations for the physicians.

Hospitals Attract Physicians. One phase of this mat-
ter that is not generally understood is the influence that
hospital facilities have on the general level of medical
care in the community. The better trained physician is
unwilling to locate where adequate hospital facilities are
not available. The net result is that the better the hos-
pital facilities, the higher the qualifications of the physi-
cians in the community, while the community lacking
hospital facilities must usually content itself with a lower
grade of medical care.

Costs. The financial aspects of a hospital organiza-

The Journal Lancet

tion must, of course, be taken into consideration. The
initial capital expenditure for the building and equip-
ment of a hospital ready to operate may range from
$4,500 to $7,000 per bed. This capital cost is influenced
by the simplicity of construction and limited facilities
permitted in smaller communities as contrasted to the
more complicated construction and more elaborate equip-
ment required for the larger and better equipped hos-
pital. Obviously the more complete the equipment and
accessory facilities, the greater the cost. Another impor-
tant factor is the skill with which the plant is planned
to permit economy of construction without sacrificing
utility. The cost of operation is somewhat variable de-
pending on the range of salary levels in the particular
community, the degree to which the physical plant is
adapted to economical operation, and the extent of the
accessory service provided.

So large a part of the operating cost is fixed, irrespec-
tive of the number of beds occupied by patients, that
the cost per patient per day is quite as much a matter
of the average percentage of total beds occupied as of
the total cost of operation. As a typical instance, the
cost reported by 100 community type hospitals for the
year ending June 30, 1941, was $6.48 per patient per
day, as compared to a cost of $4.96 per installed bed
per day. During this period the average number of beds
occupied to total beds installed was 76.64 per cent.

The operating revenue will depend both upon the av-
erage number of beds occupied, conditioned upon the
economic status of the patient treated, the proportion
who can pay full cost and the extent to which the com-
munity can be expected to assume the costs of those who
are unable to pay.

Here the economic status of the community comes
into the picture. The U. S. Public Health Service found,
for instance, that counties having an average per capita
income of $600 had eight times as many physicians per
capita as counties having an average per capita income
of $100 or less. Similar considerations would apply to
the support of the hospital.

Community Surveys. At this point in the procedure,
before establishing a hospital or health center, it is the
part of wisdom to secure the advice of a qualified and
unbiased hospital consultant. His expert appraisal of the
conditions may save the community many serious mis-
takes. Even though his conclusions may be in the nature
of an "educated guess” rather than mathematical dem-
onstration of need, it will still be far safer than any esti-
mate made by local inexperienced, or perhaps biased,
persons. Incidentally, his advice, even if against action,
may actually be of more value to the community than
any advice for positive action he might give. There is
no fixed formula by which to determine whether a given
community should or should not establish any of the
above mentioned types of facilities. It is only the sea-
soned and unbiased opinion of a qualified consultant
which can determine with reasonable soundness the ex-
tent to which a community should go in developing its
health service.

VUtMtotyt

Dr. Frederick Brown, 65, who had practised in Valley
City, North Dakota, for 18 years, died at his home
November 13, 1945, after a short illness.

Dr. Floyd F. Clark, 64, who had practised medicine
and surgery in Duluth for 36 years, died November 15,
1945.

Dr. Anthon Flath, 81, a physician in North Dakota
for 47 years, died December 4, 1945, at Stanley. Dr.
Flath was a native of Ontario, Canada, and received his
medical education at the University of Toronto.

Dr. Thomas J. Gaffney, 72, Lakeville, Minnesota,
died November 27, 1945, of heart disease and influenza.

Dr. William Walter Johnston, 71, died November 11,
1945, at Savage, Montana. A native of Byron, Minne-
sota, and a graduate of the University of Minnesota in
1904, Dr. Johnston had practised medicine in Savage
for 35 years before his retirement two years ago.

Dr. Henry W. F. Law, 74, died December 2, 1945,
at Grand Forks, North Dakota, where he had practised
for 30 years before his retirement two years ago. He
was a native of Brock, Ontario, and had resided in Han-
nah, North Dakota, before going to Grand Forks in
1913. He was associated with the Grand Forks Clinic
and was chief of staff of the Deaconess Hospital.

Dr. Frederick Walter Minty, 63, died November 25,
1945, at Rapid City, South Dakota, of a heart ailment.
Dr. Minty, a son of a pioneer Methodist missionary in
the Black Hills and father of Dr. Earl Minty of Du-
luth, had practised in Rapid City since 1907. He was
a member of the American College of Surgeons.

Dr. Victor N. Peterson, 66, died November 28, 1945,
at St. Paul, after a year’s illness. A physician in St.
Paul for nearly forty years, he was a member of the
American College of Surgeons and a former president
of the St. Paul Surgical Society.

Dr. Lee Whitmore Smith, 53, died at his home near
Poison, Montana, November 18, 1945, after an illness
of more than a year and a half. Dr. Smith, who had
practised in Butte for nearly 30 years, was a member of
the American College of Surgeons and the American
Board of Ophthalmology. A native of Wabasha, Min-
nesota, Dr. Smith was a graduate of the University of
Minnesota Medical School. He was an ardent sports-
man identified with wildlife programs in Montana.

Dr. Henry Loring Staples, 86, pioneer Minneapolis
physician, died December 23 at his home. Dr. Staples
had practised in Minneapolis from 1888 until his retire-
ment ten years ago.

Dr. Jacob Thorkelson, 69, died November 20, 1945,
at Butte, Montana. Born in Egersund, Norway, Dr.
Thorkelson came to the United States 53 years ago.
After a career as a master of sea-going vessels, he en-
rolled at the College of Physicians and Surgeons, Balti-
more, from which he was graduated in 1911. He had
practised in Montana since 1913. Dr. Thorkelson was
a member of Congress for one term.

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PHYSICIAN WANTED

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EXCEPTIONAL OPPORTUNITY
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ment room or laboratory in new office building located
in very best residential retail section. Address Box 761 A,
care of this office.

ASSISTANCE AVAILABLE

Aznoe’s, established in 1896, has available a number of
well trained physicians (diplomates of the specialty
boards, industrial physicians and surgeons, general prac-
titioners, psychiatrists, tuberculosis specialists and resi-
dents). For histories, write Ann Woodward, Aznoe’s-
Woodward Medical Personnel Bureau, 30 North Michi-
gan Ave., Chicago 2, 111.

WANTED

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pay 25c per copy or credit your 1946 subscription in-
voice with 50c on each of first 50 copies received. Busi-
ness office THE JOURNAL LANCET, 84 S. 10th St.

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January, 1946

List of Physicians Licensed by the Minnesota State

Board of Medical Examiners, November 9, 1945

(October Examination)

Name

School

Address

Berkman, David Scott

Bronson, Robert Glen

Bush, Robert Philips

Carpenter, George Tyson

Carpenter, Richard Everett

Christianson, Charles S.

Conley, Francis William

Daut, Richard Victor

Dunn, John Hartwell ....

Ellis, Franklin Henry, Jr.

Geiser, Peter Michael

Hagen, Paul Stickney

Hare, Helen Jane

Henkel, Herbert Bowman

Holt, Robert Perry

Jones, John Robert

Kennedy, Richard Loren

Krusen, Edward Montgomery, Jr.

Leinassar, Jorma Michael

Lindberg, David Oscar Nathaniel

Lowe, George Henry, Jr

Macdonald, Ian Donald

MacMurtrie, William Joseph

Aloysius, Jr.

McGuff, Paul Edward

Miller, Edward Martin

Nelimark, Donald Robert

Spray, Paul

Taylor, Ashton B.

Upshaw, Bette Young

Weed, Lyle Alfred

Winchester, Elsie Chilman

. Med. Col. of Va., M.D. 1944 Mayo Clinic, Rochester, Minn.

_U. of Minn., M.B. 1944, M.D. 1945 Minneapolis Gen. Hospital, Minneapolis 15, Minn.

...U. of Pa., M.D. 1944. Mayo Clinic, Rochester, Minn.

..Northwestern U., M.B. 1944, M.D. 1945 ..Mayo Clinic, Rochester, Minn.

U. of Chicago, M.D. 1943 Mayo Clinic, Rochester, Minn.

. U. of Oregon, M.D. 1943 Minneapolis Gen. Hospital, Minneapolis 15, Minn.

U. of Iowa, M.D. 1943 . Mayo Clinic, Rochester, Minn.

_U. of Iowa, M.D. 1945 Mayo Clinic, Rochester, Minn.

-U. of Tenn., M.D. 1941 Mayo Clinic, Rochester, Minn.

Columbia, M.D. 1944 Mayo Clinic, Rochester, Minn.

Bowman Gray Med. Col., M.D. 1944 St. Mary’s Hospital, Minneapolis, Minn.

U. of Minn., M.B. 1940, M.D. 1941 University Hospitals, Minneapolis 14, Minn.

...Rush Med. Col., M.D. 1942 Mayo Clinic, Rochester, Minn.

-St. Louis Univ., M.D. 1944 Mayo Clinic, Rochester, Minn.

U. of Okla., M.D. 1943 Mayo Clinic, Rochester, Minn.

McGill U., M.D. 1943 Mayo Clinic, Rochester, Minn.

Rush Med. Col., M.D. 1935 228 Lowry Med. Arts Bldg., St. Paul 2, Minn.

U. of Pa., M.D. 1944 .... Mayo Clinic, Rochester, Minn.

U. of Ore., M.D. 1944 Ancker Hospital, St. Paul 1, Minn.

Boston Univ., M.D. 1915 Buena Vista Sanatorium, Wabasha, Minn.

...Northwestern, M.B. 1942, M.D. 1943 Mayo Clinic, Rochester, Minn.

U. of Ore., M.D. 1944 Mayo Clinic, Rochester, Minn.

.. U. of Pa., M.D. 1943 Mayo Clinic, Rochester, Minn.

...Indiana U., M.D. 1944 Mayo Clinic, Rochester, Minn.

...Columbia U., M.D. 1944 ...Mayo Clinic, Rochester, Minn.

U. of Minn., M.B. 1945 Providence Hospital, Detroit 8, Mich.

...George Washington U., M.D. 1944 Mayo Clinic, Rochester, Minn.

.Northwestern, M.B. 1944, M.D. 1945 Mayo Clinic, Rochester, Minn.

U. of Texas, M.D. 1942 Mayo Clinic, Rochester, Minn.

U. of Iowa, M.D. 1939 Mayo Clinic, Rochester, Minn.

Rush Med. Col., M.D. 1942 Mayo Clinic, Rochester, Minn.

Clayton, Paul Algene

Craig, Marion Stark, Jr.

Davis, William Irving

Gilliland, Martha Jordan

Hazel, John Tilghman

Leavitt, Milo David, Jr.

Marshall, Helen Stewart

Parker, Warren E.

Pollard, William Henry, Jr

Pratt, Fred John

Schmidt, Edward Carl

Woodward, Robert Samuel

Fitzgibbons, Robert Joseph ....

Glynn, James Joseph

Hartigan, John Dawson

Henderson, Edward Drewry
Le Blanc, Leo James

BY RECIPROCITY

U. of Mich., M.D. 1942 Mayo Clinic, Rochester, Minn.

U. of Ark., M.D. 1944 Mayo Clinic, Rochester, Minn.

U. of Minn., M.B. 1939, M.D. 1940 Mound, Minn.

U. of Louisville, M.D. 1941 Mayo Clinic, Rochester, Minn.

Georgetown U., M.D. 1928 Mayo Clinic, Rochester, Minn.

U. of Pa., M.D. 1940 .Mayo Clinic, Rochester, Minn.

U. of Wis., M.D. 1942 Duluth Clinic, Duluth 2, Minn.

U. of Minn., M.B. 1934, M.D. 1935. Wadena, Minn.

U. of Wis., M.D. 1942 1300 University, Madison, Wis.

U. of Ark., M.D. 1944 Minneapolis Gen. Hospital, Minneapolis 15, Minn.

U. of Wis., M.D. 1940 Mayo Clinic, Rochester, Minn.

Creighton U., M.D. 1943 Ancker Hospital, St. Paul, Minn.

NATIONAL BOARD CREDENTIALS

Creighton U., M.D. 1943 .. Mayo Clinic, Rochester, Minn.

Col. of P. & S., N. Y., M.D. 1943 Mayo Clinic, Rochester, Minn.

— -Creighton U., M.D. 1943 Mayo Clinic, Rochester, Minn.

U. of Minn., M.B. 1943, M.D. 1944 Mayo Clinic, Rochester, Minn.

St. Louis U., M.D. 1941 Mayo Clinic, Rochester, Minn.

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The Ulcer Problem

Owen H. Wangensteen, M.D., F.A.C.S.
Minneapolis

IT is indeed a rare privilege to be asked to give one
of the triennial lectures of your association commem-
orating Lister, easily first among all surgeons of all
time. My sense of genuine appreciation of this high
honor is marred not alone by the knowledge that this
compliment is ill deserved, but also by serious personal
misgivings over being able to bring something to you
suitable to the occasion.

Pope once said: "His praise is lost who waits till all
commend.” So many eulogies have been spoken of
Lister, his life and his great work, that it would ill befit
me on this occasion to attempt to tell again what others
before have said with luster. If I were to attempt to
add another stone to the coping stone of encomiums with
which Lister’s life and work have been crowned, it would
appear out of place and a slight to those who have done
their work so well. Your own inimitable Archibald on a
similar occasion said: "The chorus of his praise has
become almost a liturgy, and one can only hope to write
the liturgy in somewhat different phrases.” It is fitting
in contemplating the life of this great benefactor of sur-
gery and society that we resign ourselves to the piety of
memory, renew acquaintance with his ideals, and reflect
for a moment upon the arduous labors and glory of this
great and good man. We need the example of men like
Lister more than they need our praise. On the occasion
of the Lister commemoration, it is fitting that we rededi-
cate ourselves to the noble tasks which he so greatly
advanced.

The Seventh Listerian Oration, presented before the Canadian
Medical Association, Montreal, Quebec, June 13, 1945, and first
published in the Canadian Medical Association Journal ( 53:309,
1945), from which it is reprinted with the permission of the author
and the editor of the Journal.

From the Department of Surgery, University of Minnesota Med-
ical School.

Supported by special grants for surgical research from the fol
lowing sources: Citizens’ Aid Society, Augustus L. Searle, Dr. and
Mrs. Harry B. Zimmermann, the Dr. Berenice Moriarity, and the
Robert A. Cooper Funds, and a grant from the Graduate School
of the University of Minnesota.

Accompanying publication of the first Listerian Ora-
tion by your own late John Stewart, of Halifax, the
Lister Memorial Club of your association made this an-
nouncement: "The first Listerian Oration published here-
with is very properly concerned with the life and work
of Lord Lister himself; subsequent orations may draw
not only upon the various items associated with Lister’s
life, but may include also the story of all great and
important advances in scientific surgery and medicine.”
I hesitate to be the first to break with the tradition of
dealing with surgery in a historical manner on this im-
portant occasion, but with the kind permission of your
officers I shall attempt to tell you briefly something of
the skirmishes that my associates and I have been having
with the ulcer problem. Did not Lister himself break
more forcibly with tradition in surgery than anyone else
has before or since? Having the permission of your
officers and the precedent of Lister’s own example, I will
embark on this undertaking without attempts at further
justification.

The Aspects of the Ulcer Problem to be
Discussed

This is not the place for, nor would time permit pre-
senting a general survey of the problem of ulcer. Your
own Babkin (1944) has reviewed in a comprehensive
manner the whole problem of gastric secretion and its
relation to the ulcer problem. Rather, it is my intention
in the time available to acquaint you with studies which
my associates and I have been prosecuting on phases of
the ulcer problem: (1) etiology, with special reference

to an interrelationship between the vascular and the acid-
peptic digestive factors in the genesis of ulcer; (2) char-
acterization of a satisfactory operation which will protect
against recurrent ulcer.

My associates who have lent special impetus to the
experimental phases of the work reported herein are Drs.
R. L. Varco, L. J. Hay, B. G. Lannin, K. A. Merendino,

The Journal Lancet

F. Kolouch, and I. Baronofsky. These men have suc-
cessively spent a year or more in the Experimental Lab-
oratory of Surgery. And during the last seven years,
covering the period of their tenure in the laboratory,
various phases of the ulcer problem have been worked
upon intently. All these men have had an important role
in wresting from nature the observations reported here.

Ulcer Production

Ulcer of the stomach and/or duodenum may be pro-
duced experimentally by several means. A number of
occurrences have suggested the great importance of the
acid-peptic digestion factor in the origin of ulcer. Fore-
most among these are: (1) the Mann-Williamson opera-
tion (1923), in which the bile and pancreatic juice are
diverted away from the gastric outlet; and (2) the
attachment of an isolated gastric pouch to a short intes-
tinal loop, attached in turn to the jejunum or ileum
(Matthews and Dragstedt, 1932). Since these procedures
leave no opportunity for the usual neutralization of the
acid-peptic digestive juice by the alkaline digestive juices,
ulcer follows both these operations in nearly all instances.

These circumstances, though they serve to emphasize
the significance of unneutralized gastric juice in the
genesis of ulcer, are nevertheless quite artificial. An im-
portant deterrent to general acceptance of the acid-peptic
theory in the genesis of ulcer, as suggested by these ex-
periments, was failure to produce ulcer by histamine, the
most profound known stimulant of gastric secretion.
Orndorff, Bergh, and Ivy (1935) carried out a diligent
attempt to provoke ulcer in dogs with histamine. Ten
dogs were injected subcutaneously with 2 mg. of aqueous
histamine every two hours, day and night, ten times a
day, with a 4-hour rest period daily. These daily injec-
tions extended over a period of 66 days. No ulcers were
produced, but four of the nine dogs in which the experi-
ment was completed exhibited superficial erosions in the
duodenum.

In 1939-40 Charles Code, a graduate of the Univer-
sity of Manitoba Medical School, was working in our
department of physiology at the University of Minne-
sota with Professor M. B. Visscher. Code was interested
in the effects of histamine intoxication. Our laboratory
in surgery was concerned with the problem of gastric
secretion. We fused our efforts, and through Code’s in-
terest a tool was created that has proved of real worth
in studying the ulcer problem. Code and Varco ( 1940)
implanted histamine-in-beeswax to permit its gradual lib-
eration and thereby were able to elicit a prolonged his-
tamine action. Employing 30 mg. of histamine implanted
in beeswax and injected once a day into dogs, ulcer could
be produced quite regularly with doses not much larger
than the total daily dose which was ineffective in the
hands of Orndorff, Bergh, and Ivy (1935) when in-
jected in aqueous solution.

The implantation of histamine-in-beeswax has proved
a useful tool, not only indicating the importance of the
acid-peptic factor in the origin of ulcer, but also in assay-
ing the protective influence of a given operation against
the ulcer diathesis.

In the earlier observations upon ulcer genesis reported
from this laboratory stress was placed primarily upon the

acid factor. Subsequent observations have demonstrated
that the peptic factor too is important in augmenting
the injury occasioned by unneutralized acid. Kolouch
(1945) observed that when gastric juice containing both
acid and pepsin, obtained from dogs with isolated gastric
pouches under the influence of histamine stimulation,
was dripped onto exposed mucosal surfaces of the an-
trum or duodenum in the dog, mucosal injury was
greater than when hydrochloric acid alone, of the same
pH, was employed as the dripping agent. Furthermore,
observations made during the past two years suggest defi-
nitely that ulcer may be produced by a variety of means
that fail to augment gastric secretion. In these very
experiments acid-peptic digestion is nevertheless an im-
portant agent in causing erosion and/or ulcer; that is,
without the acid-peptic digestive mixture gliding over the
mucous membrance of the stomach or duodenum, ulcer
would not occur. Before detailing some of these experi-
ments, however, I should like to summarize the evidence
on ulcer production in various animals with histamine
stimulation.

A. The histamme-in-beeswax provoked ulcer.'”’' In
Table 1 is shown, in summary, the incidence of ulcer
production in various animals when the histamine-in-
beeswax technique is employed. Only in the monkey and
in the rabbit was it difficult to produce ulcer by stimu-
lating the endogenous mechanism of the stomach to
secrete. In the dog the usual site of ulcer after histamine
was very much like the spontaneous ulcer in man; the
duodenum and the antrum were the sites of predilection.
In the chicken and duck the ulcers occurred in the giz-
zard; in the pig the squamous epithelium of the upper
end of the stomach seemed most sensitive to acid-peptic
digestion and all the ulcers occurred in the cardia with
perforation onto the pancreas. Perforation was frequent
in the cat and guinea pig. In the main, the duodenum
in most of our experimental animals, as in man, appeared
to be a favorite site of ulcer formation; in many, how-
ever, the ulcer was in the stomach, and a number of
animals presented both gastric and duodenal ulcers.

It is interesting that it was possible to produce ulcer
quite regularly in the rabbit by the histamine-in-beeswax
technique upon discarding the cellulose pulp of cabbage,

Table 1

Incidence of Ulcer Production in Various Animals
Accompanying Daily Intramuscular Implan-
tation of Histamine-in-Beeswax

A nimdl

No.

series

Daily amount
of histamine
base milligrams

No. of
Jays of
injections

No.

ulcers

Per

Cent

Dogs

4-37

87.5

Guinea pigs

2-11

75.0

Cats

3-28

80.0

Chickens

7.5

4- 9

100.0

Ducks

20-26

100.0

Swine

13-15

100.0

Woodchucks

15-20

5-30

66.0

Calves

30 to 150

1-50

50.0

Monkeys

20-50

23-59

25.0

Rabbits

7.5 to 30

5-41

12.5

’Superficial erosive ulcer.

February, 1946

carrots, and lettuce, feeding only the juice that went
through the press. By this means it was possible to get
the rabbit’s stomach empty, permitting the acid-peptic
digestive mixture an opportunity to attack the gastric
or duodenal wall directly. Perforated ulcers of the duo-
denum were produced in all four rabbits subjected to
this modification of the experiment.

B. The vascular factor in ulcer genesis. Most of us
come slowly to conclusions which are at variance with
our previously held ideas. The import of the production
of ulcers by the histamine-in-beeswax technique was to
re-emphasize the significance of the acid-peptic digestion
factor in the genesis of ulcer. "No ulcer without free
hydrochloric acid” has come to be a commonplace ex-
pression. The frequency with which a bleeding ulcer
becomes manifest for the first time in persons in the
sixth or seventh decade has undoubtedly seemed a little
unusual to clinicians who hold to the acid-peptic factor
as the important determinant in ulcer genesis. If those
patients harbored the ulcer diathesis, why did they not
manifest symptoms earlier in life?

In 1931 suction applied to an indwelling duodenal
tube became standard practice in this clinic in the post-
operative management of abdominal cases, to prevent
intestinal distension. Prior thereto hematemesis was
observed occasionally as a postoperative complication,
especially in peritonitic distended abdomens. With the
commencement of the use of suction as a routine post-
operative measure to prevent the occurrence of disten-
sion, hematemesis disappeared as a postoperative compli-
cation. Eiselsberg, it is to be recalled, described this
occurrence in 1899, and attributed it to retrograde
thrombosis of the gastric wall, reaching the stomach via
the omentum and mesentery. Payr (1907, 1910), and
Wilkie (1911) both observed that retrograde embolism
of the veins of the stomach with resultant formation of
gastric erosions and/or ulcer could be produced by injec-
tion of particulate matter into the veins of the omentum.
Wilkie’s paper is written with the clarity of style that
characterized all his work. In addition, his paper is
accompanied by beautiful illustrations, several in color.

1. Fracture and hematemesis. fii)

Case 1

In 1940, severe hematemesis was observed in a man, L. W.,
aged 36, admitted December 9, 1940, with multiple fresh frac-
tures sustained in an automobile accident. Fat was demon-
strated in the urine the day following admission. A few days
later repeated hematemesis and melena, persisting a week and
necessitating several transfusions of blood, occurred. The pro-
thrombin time and vitamin C level in the blood were normal.
The patient eventually made a satisfactory recovery and was
dismissed to his physician on February 26, 1941. There had
been no antecedent story of ulcer or bleeding.

Case 2

The above occurrence was looked upon as a fortuitous cir-
cumstance until Mrs. K. A., aged 82, was admitted directly
after having sustained a fractured neck of the left femur in a
fall on March 15, 1942. During the next few days the patient
was mentally confused and also incontinent. The hemoglobin
was 11.9 gm. On March 25 vomiting of blood and melena
occurred. There was quickening of the pulse and mild shock.
Transfusions of blood and a constant intragastric drip of Varco
formula No. II were begun on March 26; despite the transfu-
sion of 1000 cc. of blood, the hemoglobin was only 7.8 gm.

The patient’s condition worsened and death occurred March 29.
There had been no antecedent story of ulcer prior to the frac-
ture. At autopsy an ulcer 15x22 mm. was found in the first
portion of the duodenum on the posterior wall. The edges and
floor of the ulcer were soft and the base appeared somewhat
necrotic. Bronchopneumonia was present and the presence of
a fracture was verified. Microscopically, the ulcer extended
through the circular muscle of the duodenum and an inter-
stitial antral gastritis was found.

Case 3

Soon thereafter a third patient, a young man aged 17, was
admitted on July 31, 1942, 11 days after having been injured
in an automobile accident. He was unconscious for five days
following the accident. When admitted here, a compound frac-
ture of the right femur was present with considerable comminu-
tion of the shaft; there was also fracture of the right ankle,
a hematoma in the scalp, and a deep laceration of the right
hand. Hematemesis occurred on August 8, 1942, and coffee-
ground emesis thereafter was not infrequent, until death, which
occurred August 15. The patient’s course was febrile and
stormy. Blood cultures were repeatedly negative. At autopsy
the presence of multiple fractures was verified. A mucosal
erosion 5 mm. in diameter was present in the midportion of
the corpus of the stomach along the greater curvature. There
was submucosal hemorrhage about it. A submucosal area of
hemorrhage measuring 4 mm. in diameter was present at the
lesser curvature, 2 cm. above the pylorus. Four additional hem-
orrhagic areas were present in the antral mucosa, measuring
approximately 2 mm. in diameter. Microscopically, minute
miliary abscesses were observed in the heart, liver, pancreas,
and brain.

Case 4

In the meantime, a fourth patient, a Mr. E. C., aged 68,
was observed in whom melena occurred after fracture. He gave
the following story. He was admitted with a fresh fracture of
the neck of the right femur on March 27, 1942. On May 1,
1942, hematemesis and melena occurred. The stools were con-
sistently positive for blood. The patient had undergone gastro-
jejunostomy elsewhere 18 years previously for a duodenal ulcer.
He had experienced occasional transient epigastric distress in
the intervening years, but this was the first hemorrhage since
operation. An X-ray film on May 27, 1942, showed a large
stomal ulcer 2 cm. in diameter. The patient did well on an
ulcer regimen and was dismissed to his home on crutches on
May 29, 1942. There has been no recurrence of melena.

The pathological records of Dr. Bell’s department
revealed, over a 7-year period (1926—32) 15 additional
cases of fracture in which hematemesis, ulcer, and/or
erosion, gastric and/ or duodenal, were noted in the rec-
ords of the post-mortem examinations on fracture cases.

2. Experimental production of ulcer and/or erosion
by fracture or curettement of bone marrow.49-00 These
observations just reported suggested the necessity of de-
termining whether ulcer could be produced by fracture.
A series of six guinea pigs were subjected to fracture
of a femur. Some of the guinea pigs received repeated
fractures of other long bones at weekly intervals. One
developed a gastric ulcer. Two others exhibited a gastro-
duodenitis. An equal number of cats were treated in
a similar fashion. No gastrointestinal pathological results
were noted.

Fifty-two dogs were subjected to a drill hole through
both cortices of the humerus, a drill hole with curettage
of the bone marrow, or fracture. These animals were
sacrificed at various periods of time up to 23 days: 53
per cent developed gastroduodenal disease. Erosions
and/ or ulcer of the stomach or duodenum were pro-
duced in 11 dogs (21 per cent). In one instance a
perforated duodenal nicer was observed.

The Journal Lancet

This evidence suggests a causal relationship between
fracture and acid-peptic ulceration of the stomach and
duodenum. Three possible explanations have been pro-
posed: (1) A histamine effect from the fracture site,

with stimulation of gastric secretion; (2) fat embolism;
(3) a combination of these two factors.

The fasting gastric samples of 10 fracture patients
were analyzed for acid and volume. These samples were
obtained the day following fracture and for several sub-
sequent days. No stimulatory effect on the gastric secre-
tory mechanism was observed as judged in the light of
responses of normal patients without fracture.

Six dogs with isolated gastric pouches were studied.
The operative trauma consisted of a drill hole through
both cortices of the humerus, a drill hole with curette-
ment of the bone marrow, or fracture. One animal
exhibited a prolonged (24-hour) stimulation of gastric
acid and volume following fracture. This result could
not be reproduced in the same dog during a subsequent
experiment.

Subsequently 18 intact dogs (including three controls)
were subjected to a drill hole through both cortices of
the humerus. Gastric aspirations were carried out daily
for 23 days. No stimulation of the gastric response was
observed in excess of that of the control animals nor
of each individual dog’s standard fasting curve prior to
the trauma to the bone. In consequence it may be con-
cluded that a histamine effect is not the primary cause
of the observed erosions or ulcerations of the stomach
and duodenum following fracture.

3. Ulcer production by the intravenous injection of
fat:' It remained to be determined whether ulcer could
be produced experimentally by the intravenous injection
of fat. Human breast or omental fat was employed,
obtained from surgical procedures and extracted with
ether. One and one half cc. of fat per kilogram of body
weight was injected intravenously. It has previously
been stated that rabbits are quite refractory to ulcer pro-
duction by histamine alone. In each of six rabbits, whose
weights averaged 1.74 kg., a single intravenous injection
of 1.5 to 2 cc. of fat was made. Then 30 mg. of hista-
nnne-in-beeswax were implanted once daily for one to
four days. No dietary strictures were imposed on the
rabbits. A perforated ulcer occurred in each instance
except one, and that rabbit died of pulmonary embolism
shortly after the fat injection (Fig. 1). Three rabbits
were injected with fat but were given no histamine.
Ulcer did not develop. In two additional rabbits, a daily
implantation of 30 mg. of histamine -in-beeswax was
made over a period of 28 days; neither developed ulcer.

Similar studies were carried out on cats, dogs, and
guinea pigs that received no histamine. A single intra-
venous injection of fat, 1.5 cc. per kilogram in amount,
was made into each animal; of six cats injected, two
developed ulcers; one at four, the other 18 days after
the fat injection. Of two guinea pigs injected with fat,
both exhibited typical gastric ulcers. Of seven dogs
given a single intravenous injection of fat, a bleeding
duodenal ulcer was found in one dog sacrificed 14 days

after the fat injection. Of three dogs that received
30 mg. of histamine-in-beeswax daily following a single
intravenous injection of fat, all developed multiple bleed-
ing duodenal and gastric ulcers within three days after
the first injection of histamine.

Microscopic studies were made of tissues stained with
Sudan III in all the 52 animals receiving fat intra-
venously; a single block of brain, lung, kidney, and
stomach was studied in each instance. Table 2 shows

Table 2

Influence of Time Interval on Occurrence of
Fat Emboli Attending the Intravenous
Injection of Fat

No. of animals
sacrificed from
1 to 4 days after
fat injections

Amount of
fat injected

Percentage of tissues
revealing fat emboli

Lung

Brair

Kidney

Stomach

(A) 23

i a cc./kg.

73.9

47.8

Sacrificed from
5 to 21 days after
fat injection

(B) 29

1 / cc./kg.

11.1

34.4

3.7

that the identification of fat in the stained sections was
considerably higher, especially in the stomach, in the
animals sacrificed and studied within one to four days
after the fat was injected intravenously. 4a

4. Interpretation of these observations. Fat injected
intravenously does not stimulate or augment gastric secre-
tion in dogs with isolated gastric pouches. The mech-
anism of ulcer production undoubtedly is that of plug-
ging the end vessels to the mucosa; the resultant anemic
areas in the mucosa become less resistant to injury and
digestion by the acid-peptic juice than is the normal mu-
cosa. The rate of disappearance of the fat from the
mucosal and submucosal gastric vessels is rapid, as indi-
cated in Table 2. This circumstance undoubtedly ac-
counts for the fact that hematemesis, erosions, or ulcer
have not been observed more commonly to accompany
fracture of long bones in man. That fat emboli in the
lung and brain are common occurrences in patients dying
early after fracture of long bones is well known (Le
Count and Gauss, 1915; Bissell, 1916). In response to
an inquiry addressed to fifty American orthopedic sur-
geons concerning the occurrence of hematemesis or ulcer
after fracture, forty-two replies were received. None
reported observing ulcer or hematemesis in patients not
previously having ulcer. However, one instance very
similar to Case 4 above was reported to me by Dr. R. C.
Webb, of Minneapolis. His patient, like my Case 4, had
undergone gastrojejunostomy previously for a duodenal
ulcer; a temporary bleeding stomal ulcer appeared shortly
after the fracture, which responded promptly to con-
servative management. Two surgeons each reported hav-
ing observed hematemesis once after the manipulation
of a stiff joint under anesthesia.

The only previous allusion to the occurrence of ero-
sion and/or ulcer following fracture that I have been
able to find in the literature is to be found in a discus-

February, 1946

sion of a paper by Sternberg (1907),
entitled, "Experimental Production of
Gastric Ulcers in the Guinea Pig.”

Sternberg was discussing the influence
of alcohol in the production of ulcer
and the process by which acute erosions
become chronic ulcer. In the discus-
sion of Sternberg’s paper, Schridde
stated that he had twice observed fat
embolism at post-mortem in the sub-
mucosal gastric arteries accompanying
fracture. In one patient, a 70-year-old
man, there were numerous erosions
and 20 superficial ulcers. The patient
died of coma, which had persisted
following the fracture. Schmorl, in a
six-line discussion at the same meeting
of the German Pathological Society
(1907), stated that he too had ob-
served punctate hemorrhages in the
gastric mucosa due to fat embolism
following fractures and severe bodily
contusions.

Florer and Ochsner (1945) recently
reported the instance of a boy of 14
who sustained rupture of the thoracic
duct and chylothorax following in-
jury. The chyle was reaspirated and
injected intravenously. The boy died
of a perforated duodenal ulcer 25
days after he was injured. Is one
justified in wondering whether the fat
from the injected chyle attained larger
particulate size on standing in the
pleural cavity, thus giving rise to em-
bolism on injection? In other words,
did the intravenously injected fat play
an important role in the development
of the ulcer?

These studies on the relation of ero-
sion and/or ulcer to fat embolism fol-
lowing fracture or amputation are by
no means complete. With the helpful cooperation
Professor E. T. Bell and his associates of the Depart-
ment of Pathology, we are now beginning to collect evi-
dence on the presence or absence of fat emboli in the
mucosal and submucosal vessels of patients dying of mul-
tiple fractures shortly after receipt of injury. In the
few patients thus far studied, it would appear that fat
embolism of the gastric end-vessels is just as common as
it was in the experimental studies reported herein. It
may be justifiable to ask whether bacterial emboli may
not also give rise to gastric hemorrhage.

5. T ne epinephrine provoked ulcer. 4 The production
of ulcer by the intravenous injection of fat suggested
that an attempt be made to produce chronic vasomotor
arterial spasm, to note whether ulcer would follow.

Fourteen rabbits were subjected to daily intramuscular
injections of 2 mg. of powdered epinephrine and 30 mg.
of histamine dihydrochloride, computed as histamine
base, each implanted in beeswax. The difficulty of pro-

ducing ulcer in rabbits by implantation of histamine-
in-beeswax alone has already been mentioned; however,
in the 14 rabbits in which implantation of powdered
epinephrine was made in beeswax, accompanied by the
simultaneous administration of histamine -in -beeswax,
ulcer or erosion occurred in each instance. Seven rabbits
had one or more perforated gastric or duodenal ulcers.
Of the remainder, two showed bleeding gastric ulcer,
and the rest had multiple bleeding gastric ulcer in the
fundus or pylorus. There was evidence of gross hemor-
rhage into the gastrointestinal tract in all. The average
length of survival was four days. Controls given his-
tamine-in-beeswax alone up to 10 days showed no evi-
dence of either erosion or ulcer.

Two dogs were given intramuscular injections of 8
mg. of epinephrine-in-beeswax daily. One animal died
of gastrointestinal hemorrhage after four injections and
the other after two injections. Marked dilatation of the
stomach and a severe gastritis and duodenitis with mul-

Fig. 1. Perforated ulcer in stomach of a rabbit after single injection of 1.5 cc. of
human omental fat. Histamine-in-beeswax (30 mg.) was given for two days. The rabbit is
quite refractory to the production of ulcer with histamine. In other words, the intra-
venous injection of fat sensitized the rabbit to ulcer. (Illustrations of ulcer produced in
various animals by histamine accompany the paper by Hay et al., in Surg., Gyn. &
Obst., 75: 170, 1942) .

The Journal Lancet

tiple erosions and bleeding points in both stomach and
duodenum were noted in both these dogs. A small, shal-
low duodenal ulcer was noted in one. Fresh blood was
present in the stomach and duodenum in both dogs. In
two guinea pigs, 2 mg. of aqueous adrenalin were sus-
pended in gelatin and injected intramuscularly. In both
guinea pigs erosions and shallow ulcers were observed in
the stomachs after the daily administration of this dose
of adrenalin for three days. Repeated tests with adrena-
lin in aqueous form failed to reveal any definite stimula-
tion of gastric secretion in Heindenhain and Pavlov
pouch dogs.

6. The pitressin provoked ulcer. Dodds and asso-
ciates (1934) produced superficial erosions and hemor-
rhages in the mucosa of the fundus of the stomach of
several laboratory animals by a single injection of pitres-
sin. Later (1935) Dodds and his associates reported hav-
ing produced chronic ulcer with perforation in rabbits
by giving 40 cc. of the British Pharmacopoeia pituitrin
by stomach tube once a week over eight weeks. Ulcer
was also produced by giving 5 cc. of the British Phar-
macopoeia extract subcutaneously to rabbits every other
day for four injections.

Dodds and his associates (1935) failed to obtain evi-
dence of stimulation of gastric secretion with pituitrin.
On the contrary, they observed evidence that pituitrin
inhibited the usual stimulating effect of a small dose of
histamine. Nedzel ( 1938) confirmed these observations
of Dodds and his associates and stated that vascular in-
terference with local nutrition of the gastric mucosa is
the primary factor in the production of hemorrhages and
erosions. Byrom (1937) observed that the giving of
large single doses of pitressin (740 pressor units) pro-
duced gross lesions in the kidney, liver, and other organs
characterized by ischemia and necrosis. Hemorrhagic
erosions also were observed in the stomach. Byrom be-
lieved these changes to be caused by an intense arterial
spasm which produced ischemia and necrosis.

The observations of Dodds and his associates and of
Nedzel were confirmed in our own observations on cats,
guinea pigs, and rabbits. The depressant action of pitres-
sin on gastric secretion also was verified on dogs with
isolated Heidenhain or Pavlov pouches. The conclusion
is that the chronic arterial spasm invoked by epinephrine
or pitressin produces local areas of anemia in the gastric
mucosa, which then become susceptible to the acid-peptic
digestive activity of the gastric juice.

7. The production of bleeding from gastric and eso-
phageal erosions and/or ulcer invoked by obstruction of
the portal circulation. Gastric hemorrhage in obstruction
of the portal vein or its tributaries is not an uncommon
clinical occurrence. Such bleeding usually has been attrib-
uted to the bursting of mucosal or submucosal esopha-
geal varices. Patients with obstruction of the superior
vena cava exhibiting esophageal varices do not bleed,
however. May not the increased venous pressure result-
ing from portal obstruction render the gastric mucosa
more susceptible to erosion of the acid-peptic digestive
juice? It appears safe to conclude that arterial spasm of
the gastric end-vessels invites erosion of the gastric mu-
cosa by the acid-peptic digestive activity of the gastric

juice. Why should not mucosal congestion brought about
by venous stasis lead to the same result?

To test the validity of this hypothesis, the following
experiments were carried out on rabbits and dogs in three
series. In each series a partial obstruction to the normal
venous return of blood from the stomach to the portal
system was made. In two of the series the normal flow
of venous blood from the left gastroepiploic vein into
the splenic was obstructed by a tie placed proximal to
their juncture. In the third series cellophane was placed
snugly around the portal vein as it lay in the gastro-
hepatic omentum. Pearse (1940) has shown that cello-
phane, when placed around the aorta, will slowly oblit-
erate this vessel, an occurrence occasioned through the
agency of a severe fibroblastic reaction within six weeks
of the placement of the cellophane ligature. These pro-
cedures were tolerated very well by the animals, and all
animals were eating and drinking normally as soon as
the effects of the anesthetic wore off. After an interval
of two days after operation in the splenic-tie series and
an average of 113 days in the portal-tie series, the daily
administration of 30 mg. of the histamine-in-beeswax
mixture prepared after the method of Code and Varco
( 1940) was commenced. The time of sacrifice of the
dogs was determined by the occurrence of spontaneous
hematemesis, melena, or extreme weakness. The rabbits
were sacrificed at varying periods of time. In all animals
the stomachs were weighed. An effort was made simul-
taneously to garner control data on the weights of nor-
mal stomachs in both rabbits and dogs.

Results. Transient immediate increase in size of the
spleen attended partial venous obstruction of the stomach
and splenic vein. In the dogs with obstruction of the
portal vein, a well-developed collateral circulation was
noted. The veins of Retzius, the anastomosis of the su-
perior hemorrhoidal vein, the esophageal veins, and the
veins coursing through the omentum were uniformly
enlarged and prominent.

In Series 1, consisting of five dogs, the splenic, the
left gastric, and the left gastroepiploic veins were divided
and tied. Two days later the administration of 30 mg.
of histamine-in-beeswax was commenced. The dogs were
sacrificed when they appeared ill, four on the fourth day
after ligature of the splenic vein, and the other on the
sixth day. All dogs exhibited severe bleeding and there
were large duodenal and/or gastric ulcers in all. Three
exhibited erosions in the lower end of the esophagus
(Fig. 2). Five other dogs were employed as controls.
In two the veins were tied, but no histamine was given.
These dogs were sacrificed 71 days later. No ulcers or
erosions were found. In three other dogs no vein liga-
tures were made, but the dogs were given 30 mg. his-
tamine-in-beeswax daily, for two to four days before sac-
rifice. None of these exhibited erosions or ulcer. The
stomachs of all dogs with vein ligatures were distinctly
heavier than the two control dogs that received his-
tamine alone.

In Series 2 there were four dogs, in all of which the
portal vein was obstructed by a cellophane ligature. Two
received histamine-in-beeswax; two did not. The two
dogs receiving histamine were killed within three days

February, 1946

Esophagus

Dog 367 (Spl
Hist. X 4

1)08 |?I,(sMeni0,

Hist, x 4

Fig. 2. Duodenal ulcer (a) and peri-esophageal erosions (b) in the upper end of the stomach in a dog
after ligature of the splenic, left, gastric, and left gastroepiploic veins. The dog received 30 mg. of histamine-
in-beeswax daily for four days. There was considerable blood in the stomach. (a) Orientation photograph,
(b) Close-up of bleeding erosions in upper end of the stomach.

after commencement of its administration. Both these
dogs exhibited large perforating duodenal ulcers. In one
there was bleeding from an eroded esophageal varix. The
other dog exhibited multiple bleeding gastric ulcers. The
two dogs not receiving histamine had heavy stomachs,
but exhibited no ulcers. In one there was a submucosal
hemorrhage in the lower end of the esophagus. The
portal vein had been obstructed 150 days before.

In Series 3 there were 18 rabbits. The vein ligatures
were the same as in the dogs in Series 1. In nine rabbits
the vein ligatures were followed by the daily administra-
tion of 30 mg. of histamine-in-beeswax for one to seven
days before sacrifice. In eight of these nine rabbits
bleeding erosions and/or ulcer were present. In two,
bleeding erosive lesions in the lower esophagus were pres-
ent. There were nine controls. In four rabbits the vein
ligatures were carried out, but the animals received no
histamine. There were no erosions or ulcers. Five re-
ceived histamine, but the veins were not obstructed.

Neither erosions nor ulcers were observed in this group.

It is evident from these experiments that obstruction
of the venous drainage from the stomach abets the ulcer
diathesis. That is, erosions and ulcer are far more readily
provoked with histamine in the presence of portal hyper-
tension than when there is no obstruction to venous out-
flow of blood from the stomach. The difficulty of pro-
ducing ulcer in rabbits by histamine alone has been men-
tioned already. However, as is indicated herein, bleed-
ing ulcers and erosions follow regularly when histamine
administration is preceded by ligature and division of
the splenic vein. In the dog, too, ulcer is produced regu-
larly in a surprisingly short time when the venous drain-
age from the stomach is obstructed, accompanied by the
administration of histamine. Esophageal varices were
observed regularly in the experiments of longer duration,
in which the portal vein was obstructed. Esophageal
erosions were observed in several of the dogs.

Another striking finding was the uniform increase in

weight of the stomachs of both rabbits (see Table 3)
and dogs, in which obstruction to the venous outflow
from the stomach had been established. Microscopically,
this occurrence appears to be due to an edema of the
entire gastric wall, but especially of the submucosa.
Erosion of the mucosa by acid occurs readily when the
blood supply has been altered by obstructing the venous

outflow- Table 3

Weights of Stomachs of Rabbits Subjected to Splenic
Vein Left Gastric and Gastroepiploic Vein
Ligation With or Without Histamine

No. of
rabbits

Procedure

Average weight
of rabbits

A verage weight
of stomachs
in grams

Splenic-tie

1.8 kg.

32.03

Histamine
No splenic-tie

1.8 kg.

21.4

Controls:

No histamine

Histamine-in-
beeswax 30 mg.
every day for
17, 21, 21, 28
days, respectively.
No splenic-tie

1.8 kg.

21.3

C. Clinical observations. In this section it is my pur-
pose to draw attention to two clinical features relating
to the preceding recitation of experimental observations.
The first of these relates to a group of cases presenting
occult bleeding from the gastrointestinal canal, in which
antecedent studies, if made before shock and severe
anemia, supervened, are negative. The conditions rep-
resented in the case histories to be recited are well-known
pathological entities. The cause of the bleeding remains
obscure and death supervenes because of uncontrolled
hemorrhage. At autopsy the surprise finding is usually
a small superficial erosion with a sclerotic artery in the
base of the erosion. If no ulcerative lesion in the mu-
cosa is detectable grossly, microscopic examination dis-
closes either an arterial thrombosis of a segment of the
gastric wall or an ulcerative gastritis with atrophy of
the mucous membrane. My special purpose in listing
these cases is to indicate that the gastric mucous mem-
brane is frequently a source, if not the usual source of
occult bleeding from the gastrointestinal canal; and that
a 75 per cent gastric resection, as is done for ulcer, will
usually rescue these patients from death from hemor-
rhage.

The second group is represented by four patients with
portal hypertension caused by cirrhosis of the liver or
thrombophlebitis of the portal and/or splenic vein. In
this group of patients, all of whom have presented severe
anemia from hematemesis and/or melena, an extensive
(90 per cent) gastric resection has been done on the
thesis that the bleeding was an erosive process occasioned
by acid-peptic digestion of the gastric and lower esopha-
geal mucous membrane in the presence of portal hyper-
tension causing venous stasis. The clinical and X-ray
diagnosis of the cause of bleeding in all these patients
has been esophageal varices.

1. Hematemesis and melena from superficial gastric

The Journal Lancet

erosion, arterial thrombosis of a gastric vessel, or ulcera-
tive gastritis.

Case 1*

Mr. H J., aged 44, admitted June 5, 1944, because of
hematemesis and melena. Four transfusions for bleeding and
shock before admission. Hemoglobin on admission, 4 gm.
Hematemesis continued and despite several transfusions hemo-
globin was brought only to 6.5 gm. Exploration on June 7.
No lesion felt in the stomach or duodenum. A 75 per cent
gastric resection was done and in the excised specimen, high on
the lesser curvature, there was a tiny shallow ulcer about 2 mm.
in diameter. The removed stomach weighed 130 grams. Micro-
scopically, there was atrophy of the mucosa. There has been no
recurrence of bleeding. On January 30, 1945, the hemoglobin
was 14.2 gm. The patient reported again on May 2, 1945,
stating that he was well and working.

Case 2

Mrs. S. P., aged 56, admitted July 26, 1944, because of
hematemesis and melena. Five transfusions were given prior to
admission and the hemoglobin on arrival was 6 gm. By July
31, 1944, the hemoglobin had risen under large daily trans-
fusions of blood to 11.6 gm. Exploration was done July 31,
1944, under cyclopropane anesthesia. No lesion in the stomach
could be seen or felt, but a 75 per cent gastric resection was
carried out. The removed stomach weighed 130 gm. High up
on the lesser curvature, and just a little removed from it on the
posterior wall, there was a shallow ulcer 3 mm. in diameter.
Microscopically, its base was necrotic; there was also atrophy of
the mucous membrane, with some leucocytic infiltration.

Case 3

Mr. R. E., aged 48, admitted January 10, 1944, because of
hematemesis. The hemoglobin was 4 gm. A diagnosis of car-
cinoma of the fundus of the stomach was made. After mul-
tiple transfusions, hemoglobin came up to 14.2 gm. On ad-
mission blood pressure was 120/65, but the patient gives a
story of previous hypertension and the retinal vessels show evi-
dence of sclerosis. The patient was prepared for operation by
constant intragastric dripping of a high protein and carbohy-
drate and low fat diet (Varco II). Transthoracic exploration
was done February 14, 1944. The spleen was larger than nor-
mal, and the main splenic artery appeared to run directly into
the fundus of the stomach, high up on the greater curvature.
The fundus of the stomach to the left of the esophagus felt
rather thick and imparted a corrugated feel to the palpating
finger. The spleen and a piece of fundic stomach 6x4 cm.
were excised. This excised specimen was then subjected to
X-ray examination. The arteries in the gastric wall exhibited
considerable calcification in the X-ray film. On microscopic
study calcification as well as thrombosis were apparent. The
bleeding apparently was occasioned by the plugging of the end
vessels in the gastric wall. The patient returned for observa-
tion on September 19, 1945. He was well and there has been
no further bleeding.

Case 4

Mrs. A. S., aged 49, admitted November 9, 1944, because
of repeated melena. The patient is quite obese. She was hos-
pitalized five times during the past year because of melena.
X-rays of the alimentary tract were negative, as were gastro-
scopic and proctoscopic examinations. Hemoglobin 7.9 gm.
Exploration on November 10, 1944. No findings. A 75 per
cent gastric resection was done on the thesis that a small bleed-
ing point, not palpable through the gastric wall, was present.
The removed specimen weighed 140 grams but showed no
bleeding point. Microscopically an ulcerative gastritis was
present. The patient did well and the hemoglobin had risen to
12 gm. at time of dismissal. There has been no recurrence of
melena and when the patient returned for observation on May
29, 1945, the hemoglobin was 13.1 gm.

Case 5

Mr. F. K., aged 45, admitted July 5, 1944, because of hemat-
emesis and melena. The hemoglobin was 7 gm. The patient
had been studied in the out-patient clinic on several occasions
over the preceding six years because of abdominal distress. Re-
peated X-ray studies of the gastrointestinal tract had been nega-
tive. Seven liters of blood were given prior to operation on

* See p. 64 for follow-up notes.

February, 1946

July 11, 1944, at which time the hemoglobin was 6.9 gm.
Exploration save for a few hemorrhages in the upper jejunum
was negative. Dr. R. L. Varco called me to the operating room.
I advised him to resect the stomach, indicating that one such
resection already had been done by me for occult bleeding. The
hemorrhages in the jejunum, however, appeared to be a more
tangible source of the bleeding, and he removed a segment of
the upper jejunum, which exhibited several hemorrhagic areas
but no ulceration. The patient did poorly after operation, and
continued to bleed. Six liters of blood were given in the post-
operative period. The patient died of hemorrhage on July 17th.

At autopsy a very shallow erosion 2 mm. in diameter and
less than 2 mm. in depth was found on the lesser curvature
near the incisura angularis. There was an open vessel in its
base. Additional areas of hemorrhage, very much like those
observed at operation, were noted in the jejunum. Both the
lumen of the ileum and the colon contained considerable blood.
Microscopic study of the ulcer base revealed fresh granulations
and a rather large arteriosclerotic artery in the submucosa
beneath the ulcer.

Discussion

The older pathological literature contains numerous
references to patients who have come to autopsy in which
death occurred from bleeding from a small, superficial
erosion in the gastric mucous membrane, in which there
was an open artery in the base. Lewin (1908) reviews
the earlier literature and lists additional cases of his own.
Instances of this sort already had been described by
Gallard in 1884. Budav (1908), in reporting such an
instance of fatal hemorrhage from a small erosion in the
gastric fundus, located with difficulty at autopsy, states
that the intimal thickening of the gastric arteries in the
submucosa is frequently greater than in far larger vessels.
Even extensive formal pathological studies relating to
sclerosis of visceral arteries rarely mention the gastric
arteries (Brooks, 1906; Dow, 1925). Arteriosclerosis,
out of proportion to that found in the arteries of the
body as a whole, may be encountered as a surprise find-
ing in any vessel. Schwyzer (1907) reports such an in-
stance, in which only the coronary arteries exhibited more
arteriosclerotic changes than the gastric arteries.

Ophuls (1913) and Boles and associates (1939) stress
arteriosclerosis of the gastric arteries in patients with
ulcer as a part of a general process. Fetterman (1935),
reporting from the Toronto General Hospital, indicates
that intimal thickening of the submucosal arteries in re-
sected stomachs removed at operation from patients with
ulcer is a frequent finding.

Whereas such erosive processes as those reported here-
in appear ordinarily very innocent when the specimens
are examined, the persistent bleeding from these areas
belies their harmlessness. A sclerotic vessel does not close
readily, and it is to be remembered that it is an artery
that is opened usually. In a fatal hemorrhage, attending
a mediastinitis following perforation of the cervical
esophagus in which the carotid sheath was opened by
me at operation to effect a more secure closure of the
esophageal perforation, I was very much surprised to
note that the bleeding occurred from the carotid artery
(1938). My inference was that the thinner walled jugu-
lar vein should have been opened. Undoubtedly, how-
ever, the pulsations of the artery caused it to be the more
easily eroded by the suppurative process.

Disse ( 1904) states that an end artery going out to
the mucosa from the submucosal vessels supplies an area

2.5 mm. in diameter. The plugging of such vessels in
older patients may be the precursor of bleeding from an
erosive lesion.

2. Extensive (90 per cent) gastric resection for erosive
hemorrhage in portal hypertension.

Case 1

Mr. F. K., aged 59, admitted to medical service January 27,
1945, because of recurrent hematemesis first noticed in 1938.
In March 1944 esophageal varices were ligated elsewhere
through a left thoracic approach. The patient bled again before
leaving the hospital and there have been three additional spells
of hematemesis since. A carcinoma of the right bronchus close
to the carina also has been demonstrated since the ligation of
the esophageal varices. The hemoglobin, when the patient was
first seen in the medical outpatient department, was 7.52 gm.
On February 6, 1945, a few days after admission to the med-
ical service, the hemoglobin was 9 gm. On February 9, 1945,
patient began bleeding again and 500 cc. of blood were given
daily by the medical service over a period of five days; a total
of 2500 cc. was given. At the end of this time the hemoglobin
was 7 gm. After transfer to surgery, a liter of blood was given
daily for nine days, including the day of operation; the hemo-
globin rose slowly to 12.3 gm. Blood was demonstrated con-
stantly in the stool. Gastric analysis without histamine showed
a maximum of 27 free acid and a total of 39°. A bronchoscopy
done on February 5, 1945, showed a squamous cell carcinoma
to be present in the right main bronchus. The X-ray findings
of the chest were consistent with a carcinoma of the right lung.
Liver function studies were normal. There was no ascites.

On February 23, 1945, a 90 per cent gastric resection was
done on the thesis that an increased portal pressure produced a
passive congestion of the gastric mucous membrane, which, in
the presence of free hydrochloric acid, made the mucous mem-
brane more vulnerable to acid-peptic digestion. In other words,
it is believed that bleeding from esophageal or gastric varices
is primarily an erosive rather than a bursting process. The
blood loss in the operation was 1190 gm.

The spleen, also large, was removed. It weighed 870 gm.
The removed stomach weighed 225 gm. The portal and splenic
veins were both large, and their walls, as in an atheromatous
process, were somewhat thick. The portal pressure was 25 cm.
of saline solution. The liver appeared normal. The operative
diagnosis was, therefore, primary thrombophlebitis of the portal
and splenic veins.

The microscopic study of the spleen showed a condition of
fibrosis consistent with the diagnosis of Banti’s disease. The
liver was normal microscopically. There were no areas of atro-
phy in the gastric mucosa. There was a moderate amount of
intestinal antral gastritis present, as is commonly observed in
duodenal ulcer.

The patient did well after operation, and the hemoglobin
promptly rose to 14 gm. There has been no further evidence
of bleeding. The patient was dismissed on March 6, 1 1 days
after operation. On March 27 he returned for excision of the
right lung, which also was done by me on April 4. The lesion
in the bronchus was quite near the carina, necessitating ampu-
tation close to the bifurcation of the trachea. The lung was
universally adherent, but was excised without difficulty. The
lung weighed 620 gm. There was no tumor in the removed
lymph nodes. The tumor in the bronchus extended over a dis-
tance of 3 cm., and practically occluded the bronchus. The
biopsy diagnosis of squamous cell carcinoma was confirmed.

A transfusion of 1000 cc. of blood was given for this opera-
tion; the blood loss in operation was 1450 gm. This is the only
transfusion the patient has had since gastric resection. The
patient did very well after operation, manifested very little
operative reaction, and was dismissed on April 15, 11 days
after operation. The hemoglobin on April 11 was 10.5 gm.

There has been no melena or hematemesis since the gastric
resection in February. The hemoglobin on May 18, 1945, was
10.9 gm., and 12.2 gm. on June 5. The patient’s weight was
122 pounds, 10 pounds less than before gastric resection and
6 pounds more than at the second admission for excision of
the right lung. He believes he is making definite progress and
appears to be doing very well.

The Journal Lancet

Case 2

Baby boy, R. O., aged 3. On July 28, 1944, splenectomy was
done because of repeated hematemesis and melena. The re-
moved spleen weighed 170 gm. The liver appeared nodular
and cirrhotic. A piece removed for biopsy showed definite
cirrhosis microscopically. The patient was dismissed August 8,
1944. On April 11, 1945, the parents brought him back be-
cause of recurrent melena. In hospital vomiting of blood oc-
curred, necessitating transfusions for shock. The hemoglobin,
which had been 13.4 gm. on the first admission, fell to 5.6 gm.
Linder daily transfusions of 250 to 500 cc. of blood, the hemo-
globin rose to 10.7 gm. on April 23, 1945, at which time a
90 per cent gastric resection was done. The liver appeared
somewhat more nodular than at the last operation. The portal
venous pressure was not determined. A specimen withdrawn
prior to operation for gastric analysis contained largely blood.
No transfusions were given after operation, and the hemoglobin
rose to 14.2 gm. Blood disappeared from the stool and when
the patient left the hospital on May 6, 1945, he was eating well.

Case 3

Mrs. M. V., aged 62: periodic melena, vomiting, and diar-
rhea over a period of years have been the patient’s complaints.
She also has pain in the back. X-ray examination discloses
a hemangioma in the twelfth dorsal vertebra. The spleen is
palpable and is believed to be enlarged. There has been blood
in the stool persistently, and the hemoglobin was 4.5 gm. upon
admission. Theie was free hydrochloric acid in the gastric
juice (59°). Recently ascites has developed. The hemoglobin
in July 1942, done elsewhere, was 7.4 gm. Between episodes of
melena and diarrhea the hemoglobin improves. After the trans-
fusion of 3 liters of blood, and iron and liver extract therapy,
the hemoglobin rose from 4.5 to 12.9 gm.

Operation was done May 24, 1945. The spleen was large
and weighed 520 gm. upon removal. The liver appeared to be
definitely cirrhotic. A small piece of the liver edge was removed
for biopsy. The portal venous pressure measured in one of the
veins of the great omentum was 35 cm. of saline solution. There
was a good deal of new vessel formation in the mesenteries.
The veins of the mesentery and bowel appeared very prominent.
The spleen was excised. A 90 per cent gastric resection also
was done, with the consideration in mind of reducing the
capacity of the stomach to secrete acid. The resection was very
difficult and tedious because of the vascularity and thickening
of the suspensory ligaments of the stomach. The removed
stomach weighed 160 gm.; there were no erosions. Microscop-
ically there was antral gastritis and cirrhosis of the liver with
marked fibrosis. The present hemoglobin is 10.8 gm. The
patient is still in the hospital under observation because of
fever suggesting the possibility of a subphrenic abscess.*

Case 4

Mrs. E. H., aged 27, admitted May 21, 1945, because of
hematemesis, melena, and a feeling of faintness. Blood has
been present persistently in the stool since May 19, 1945. The
hemoglobin was 8.8 gm. In 1938 I removed this patient’s
spleen because of recurrent hematemesis and melena. A number
of accessory spleneculi were found. The diagnosis was thrombo-
phlebitis of the splenic vein. The liver appeared normal. There
has been no recurrence of hematemesis or melena until just
before admission. There is no ascites; liver function tests are
normal. The patient had free hydrochloric acid in all four
samples; the highest value was 36°. Three transfusions of
blood were given, and the hemoglobin rose to 11.7 gm. on the
day of operation. On June 4, 1945, a 90 per cent gastric resec-
tion was done. The liver appeared normal, no surviving splenic
tissue was observed. The portal venous pressure measured in
an omental vein is 49 cm. of saline solution. The mesenteric
veins appeared full and were very prominent. The suspensory
ligaments of the liver were extremely vascular and thick, making
dissection difficult. The omentum was universally adherent in
the upper right quadrant and contained prominent veins. The
fundic portion of the stomach was intimately adherent to the
left diaphragm and pancreas over a wide extent. The removed
stomach weighed only 114 gm. There has been little operative
reaction. The patient is convalescing nicely from the procedure.

•This patient died subsequently of a subphrenic abscess which
was managed in too dilatory a manner.

Discussion

The first operation in this group of patients with por-
tal hypertension was done just a few months ago, and
a longer lapse of time will have to occur before one can
say with assurance that this is a satisfactory manner in
which to control the bleeding in such patients. A fairly
large number of patients with cirrhosis of the liver, as
Eppinger (1937) has indicated, die of hemorrhage before
ascites or liver insufficiency supervene. The operations
proposed hy A. O. Whipple (1945), of excising the
spleen and left kidney and uniting the veins of these two
organs over a Blakemore tube, or of making a direct
Eck fistula between the portal vein and the vena cava,
obviously constitute a more direct attack upon the prob-
lem of portal hypertension. However, an Eck fistula per
se apparently does not constitute an altogether harmless
diversion of portal venous flow, as indicated by the earlier
report from Pavlov’s laboratory (see Enderlen et al.,
1914) as well as by the more recent report of G. H.
Whipple and his associates (1945).

It perhaps should be indicated, too, that gastric resec-
tion in a patient with portal hypertension may be a more
difficult operation than in a patient with ulcer. The
omenta and tethering membranes and ligaments of the
stomach are thickened up, owing to the new vessel pro-
liferation. Dissection, in consequence, may be difficult,
because of obliteration of normal tissue planes. In the
ordinary gastric resection for ulcer the operation may be
accomplished with a blood loss of 300 cc. or considerably
less; owing to a tendency for all the dissected surfaces
in portal hypertension to bleed, the blood loss is usually
much greater. The employment of dry gauze sponges
and weighing them at operation (1942), 66 however,
keeps the surgeon apprised continuously of the magni-
tude of the blood loss, which loss may be replaced by
an equal amount of transfused blood.

At the moment we are engaged in determining whether
the bleeding from gastric and esophageal erosions, which
can be created experimentally by the administration of
histamine in the presence of portal obstruction, can be
prevented by preliminary extensive gastric resection. If
such should prove to be the case it would augur well
for the proposal of subjecting patients with hemorrhage
from increased portal venous pressure to the operative
procedure described here.*

Characterization of a Satisfactory
Operation for Ulcer

The second portion of this presentation will concern
itself with an attempt at evaluation of the criteria of a
satisfactory operation for ulcer. As indicated in the re-
ports of vital statistics by the United States Department
of the Census, there has been a significant drop in the
mortality from both appendicitis and intestinal obstruc-
tion in the last decade. On the other hand, the mor-
tality from duodenal and gastric ulcer per 100,000 pop-

•Preliminary experiments on dogs suggest definitely that a 90
per cent gastric resection affords real but not absolute protection
against the histamine provoked ulcer in the presence of portal
hypertension. Under these very same circumstances a 75 per cent
gastric resection affords no protection against the histamine pro-
voked ulcer — an occurrence which indicates how strongly portal
hypertension abets the ulcer diathesis.

February, 1946

illation has continued very much the same over a period
of thirty years. The complications of perforation, hem-
orrhage, and obstruction account largely for this mor-
tality. In order to prevent perforation we must learn to
control the ulcer diathesis. The frequency with which
the tragic complication of perforation occurs suggests
that much remains to be learned concerning the control
of the ulcer problem by conservative means. However,
the opportunity should not be neglected to point out
that the general application of the principles of closure
of such perforations, as first enunciated by Roscoe Gra-
ham (1937) of the University of Toronto, have had a
telling effect upon the mortality from perforation.

Surgeons have concerned themselves in an empirical
fashion with the problem of attempting to relieve the
ulcer diathesis for a period of more than fifty years.
Out of this experience has grown a mass of conflicting
data with reference to the accomplishment of the sur-
geon in the management of ulcer, without a clear-cut
definition of the criteria of an acceptable operation for
ulcer. The surgeon knew only that the object of his
craftsmanship was to prevent ulcer recurrence, but he
did not know how that end was to be attained, nor did
he know or understand the items promoting or abetting
the ulcer diathesis. Little wonder that he groped about
aimlessly, striving to devise new procedures or modify
old ones that might achieve his objective. Little wonder
that the high incidence of recurrent ulcer after opera-
tion justified internists, actuaries, and the medical depart-
ments of our allied forces in their distrust of what sur-
geons affected to be able to accomplish for the patient
with an ulcer refractory to medical management.

Evaluation of the criteria of a satisfactory operation
for ulcer. This story has been told in part previously.
a7,38,fis The histamine-in-beeswax technique has proved
a most useful instrument in assaying the worth of a
given operation. Before that tool became available, how-
ever, this study already was on its way. In brief, it may
be said that in patients as well as in dogs to which his-
tamine-in-beeswax is administered, to note whether a
given operation will protect against the histamine-pro-
voked ulcer, the results are in concurrent agreement. In
man a study of the incidence of recurrent stomal ulcer
after each type of operation is the method of procedure;
obviously not a commendable manner in which to deter-
mine the criteria of a satisfactory operation.

From these studies, the characters of a satisfactory
operation that protects against recurrent ulcer appear to
be: (1) an extensive gastric resection (75 per cent),
affording promise of reduction in gastric secretion; (2)
excision of the antral mucosa. This proof emanates from
operations on man alone, but appears to be well substan-
tiated in the reports of Ogilvie ( 1938) , Wangensteen
and Lannin (1942) and McKittrick, Moore, and War-
ren ( 1944) . The patient reported upon previously 68
from this clinic continues well, now almost five years
after excision of the antral fragment of mucosa left be-
hind in the first operation, in which a three-quarter
resection was followed by a recurrent stomal ulcer. (3)
Fairly complete excision of the lesser curvature of the

stomach appears justified, in that ulcer occurs primarily
in the unrugated portions of the first portion of the duo-
denum and along the lesser curvature of the stomach.
Kolouch’s (1945) drip experiment suggests that un-
rugated mucosal strips are more susceptible to injury,
in that periodic momentary escape from the unrelenting
dripping of the acid-peptic digestive juice is not permit-
ted the unrugated surface. Hence the greater vulnera-
bility of the unrugated duodenal cap and the lesser
curvature to the ulcer diathesis. (4) The importance of
a short afferent duodenal loop in effecting gastrointes-
tinal continuity after an extensive gastric resection ap-
pears to have been established. This item is as suscep-
tible of proof in the dog as in the patient. The proof
from both the experimental laboratory and the clinic
will be cited herein, because it is my belief that this
item is still, in many hands, an important factor in ulcer
recurrence after an otherwise satisfactory operation for
ulcer. The matter is important enough to warrant reci-
tation in some detail.

The problem was subjected to experimental scrutiny in
the following manner. Three series of experiments were
carried out in dogs. In each series a three-quarter gastric
resection (75 per cent) including excision of the pylorus
and antrum was carried out. The only variable was the
length of the proximal afferent duodenojejunal loop.
The operations were carried out on the Billroth II plan
of procedure, with the Hofmeister modification of deal-
ing with the lesser curvature.

A. Proof of the importance of a short afferent duo-
denal loop in gastric resection. ' '

Series 1. Eleven dogs were used. These dogs were subjected
to an extensive gastric resection (75 per cent) . The gastro-
jejunostomy was performed as close to the inverted duodenal
end as was technically feasible, the distance from the blind duo-
denal end varying from 12 to 15 cm. After this operative pro-
cedure three months were allowed to elapse. Then 30 mg. his-
tamine base in beeswax, prepared after the method of Code and
Varco (1940), was injected intramuscularly each day. A total
of 40 to 45 injections were carried out on each animal. The
animals were sacrificed after the last injection. In spite of
severe histamine stimulation, not one gastrojejunal ulcer was
encountered. This result is significant.

Series 2. The identical operation described above (75 per
cent gastric resection) was performed on seven dogs, with one
difference. In these animals a longer afferent duodenojejunal
loop was employed. The distance from the inverted duodenal
end to the site of gastrojejunostomy varied from 27 to 78 cm.
Similarly, a rest period of three months was allowed to inter-
vene. Following this period, 30 mg. of histamine base in bees-
wax were injected intramuscularly daily.

A large, frequently perforated gastrojejunal ulcer was ob-
served in each instance (100 per cent). These results are in
striking contrast to the results in Series 1. Three of the seven
dogs in Series 2 died of generalized peritonitis attending per-
foration of a stomal ulcer. The dogs with the longest afferent
duodenojejunal loops had the shortest survival periods.

Series 3. In a group of four dogs gastric resection was done,
varying in extent from 50 to 75 per cent. The length of the
afferent duodenojejunal loop in these four experiments varied
between 78 and 144 cm. These dogs received no histamine.
Two of the four dogs died of spontaneous perforation of a
gastrojejunal ulcer located just beyond the efferent outlet
(Fig. 3). One dog, in which a 50 per cent gastric excision had
been done, accompanied by an afferent duodenojejunal loop of
78 cm., was sacrificed 210 days after operation. There was
no stomal ulcer. One other dog is still alive and apparently
well more than two years after operation,

The Journai. Lancet

Fig. 3. Spontaneous perforation of a stomal ulcer (no histamine) in a dog in which a 50 per cent gastric
resection (Billroth II) had been done, employing a long afferent duodenojejunal loop measuring 78 cm. in
length from the inverted duodenal end. Death occurred from peritonitis 420 days after the operation. The
over all length of the small intestine was 323 cm. Of seven dogs in which 75 per cent gastric resection was
done, employing a long afferent duodenojejunal loop, followed by the administration of histamine-in-beeswax,
all developed perforating or perforated stomal ulcer. In dogs that have had a 75 per cent gastric resection,
accompanied by a short afferent duodenal loop, a stomal ulcer cannot be produced by histamine.

Comment

The results of these experiments are striking. In 11
dogs (Series 1), with an extensive gastric resection (75
per cent), in which the afferent duodenal loop was short
(12 to 15 cm.), stomal ulcer could not be provoked in
a single instance by profound stimulation in gastric secre-
tion with histamine-in-beeswax. In three of the 1 1 dogs
superficial gastric erosions were noted. In seven dogs
(Series 2), in which the extent of the gastric resection
was the same (75 per cent), the only difference being
that the afferent duodenojejunal loop was longer (27 to
78 cm.) , a gastrojejunal ulcer occurred in each instance
following histamine stimulation. In a third series of four
dogs with long afferent duodenojejunal loops, which re-
ceived no histamine after gastric resection, varying in
extent from 50 to 75 per cent, two (50 per cent) de-
veloped spontaneous perforated gastrojejunal ulcer.

B. The importance of the length of the afferent duo-

denojejunal loop in indicating whether stomal ulcer will
occur in the Schmtlinsky-McCann operation. There has
been much confusion and conflict of opinion concerning
the item of complete intragastric regurgitation as it re-
lates to the Schmilinsky-McCann operation. Schmilinsky
(1918) suggested placement of the afferent duodeno-
jejunal loop, in the Billroth II type of gastric resection,
back onto the stomach in such a manner that all the duo-
denal contents drained back into the stomach. He termed
this arrangement an "internal pharmacy” for neutraliza-
tion of gastric acidity, an item that is looked upon as a
desirable factor in gastric resection for ulcer. McCann
( 1929) reported that he had produced gastrojejunal
ulcer in 80 per cent of 26 dogs operated upon according
to the Schmilinsky plan. A number of other investiga-
tors, Ivy and Fauley (1931), Weiss, Graves, and Gur-
riaran (1932), Graves (1935), Maier and Grossman
(1937), and Wangensteen and his associates (1940) re-

February, 1946

peated the McCann experiment with rather indifferent
results. None of these investigators was able to confirm
McCann’s observations of a high incidence of gastro-
jejunal ulcer following complete drainage of the duo-
denal loop back into the stomach. Wangensteen and his
associates (1940) indicated that disastrous results attend-
ed performance of the Schmilinsky operation on man
and suggested that constant regurgitation of the duo-
denal loop content back into the stomach might stimu-
late the second or gastric phase of gastric secretion in-
terminably. Kesavalu and Mann (1943) have shown,
in dogs with isolated gastric pouches, that the Schmilin-
sky procedure definitely enhances secretion from the
pouch.

Methods of study and residts. A total of 17 dogs
were studied. The Schmilinsky-McCann operation of
complete intragastric return of the entire content of the
duodenal loop was performed in each animal.

In the first series of 1 1 dogs the operation was accomplished
in the following manner. These dogs were anesthetized, and
under septic conditions a laparotomy was performed. The py-
lo us of the stomach was excised. The duodenal end was then
closed and inverted in the usual fashion by means of inter-
rupted cotton sutures. At distances of 8 to 15 cm. from the
inverted duodenal stump the intestine was transected. The
proximal transected intestine was anastomosed onto the stomach.
Thereby complete intragastric regurgitation of the duodenal
contents, including bile and pancreatic juice, was assured. The
end of the distal loop of intestine was closed and inverted. A
gastrojejunostomy, end-to-side, was then performed between
the end of the stomach and the side of the distal transected
intestine.

Following operation convalescence was rapid. After a brief
period of time normal activity was assumed and appetite re-
gained. At various intervals from 72 to 360 days these ani-
mals were sacrificed. In the 1 1 dogs in which a short proximal
duodenal loop was employed in the Schmilinsky-McCann pro-
cedure, gastrojejunal ulcer occurred only once (9.1 per cent).

A second series of Schmilinsky-McCann operations was sub-
sequently carried out on six dogs. The operation was identical
in all details with that described in the first series of animals,
with one exception. In the first series, the intestine was tran-
sected a short distance from the inverted duodenal stump. Thus
a short proximal loop was obtained. However, in this second
series of dogs the transection of the intestine was carried out
at a lower level. The length of the proximal loop from the
inverted or "blind” duodenal end varied from 76 to 90 cm.
The transplantation of the proximal loop was high on the
stomach in some instances, low in others. In this second series
a short period of normal response was noted. As time pro-
gressed, however, the dogs became irritable, anorexic, and lan-
guid. Coma and death followed. The average survival period
was 79.7 days. The area of the transplantation (high or low)
of the proximal loop onto the stomach did not appear to alter
the end result. The incidence of gastrojejunal ulcer in this
series was 83.3 per cent (five out of six dogs). Four of the
six dogs exhibited perforated peptic ulcers.

Comment. These results clarify the confusion in the
literature concerning the results of complete intragastric
drainage of the duodenal loop in dogs. The results of
the experiments reported here suggest that the divergent
results obtained by previous investigators are explicable
on the basis of the length of the afferent loop employed.
The agency through which the length of the afferent
loop in the Schmilinsky procedure influences so definitely
the occurrence of stomal ulcer is not apparent. One
thing is clear, however. Exclusion of hydrochloric acid,
the best physiological stimulus for the secretion of pan-
creatic juice with high buffer value, from contact with

the duodenal mucosa, the segment of mucosa richest in
secretin, affords a plausible explanation for the greatly
increased incidence of stomal ulcer in the experiments in
which the long afferent loop was employed.

C. Why does a long afferent duodenojejunal loop
invite stomal ulcer? u An attempt was made, without
too much success, to determine definitely what the factor
or factors are in a long afferent duodenojejunal loop that
contribute to the occurrence of stomal ulcer. The opera-
tions depicted in Figure 4 were carried out in 12 dogs.
The three items examined with respect to their impor-
tance in the genesis of stomal ulcer were: (I) secretin

factor; (2) the factor of spatial separation of alkaline
and acid digestive secretions; (3) the sensitivity factor,
implying an increased susceptibility of the mucosa of
successively lower segments of the small intestine to
injury by the acid gastric secretions.

Methods. Six modifications of the total intragastric
duodenal drainage operation of Schmilinsky and Mc-
Cann were carried out in a series of 12 dogs (Fig. 4).
The operations were devised to study the influence of
both short and long afferent duodenojejunal loops on the
development of stomal ulcer just beyond the efferent
gastric outlet, with special reference to an attempt to
evaluate the significance of the three factors enumerated
above. In other words, in addition to varying the length
of the afferent loop, the site of the efferent outlet of
the stomach was varied, permitting testing of the im-
portance of the secretin factor and the item of mucosal
susceptibility to corrosion by the acid gastric secretions.
These latter objectives of the study necessitated some
rather complicated operative procedures. By transecting
the duodenum just beyond the major pancreatic duct
and interposing a loop of ileum between the proximal
portion of the duodenum and the stomach, or by excis-
ing a portion of the duodenum and the upper jejunum
in other experiments, it became possible to vary all the
factors we wished to scrutinize. In some experiments the
afferent loop was long, yet the requirements of a func-
tional secretin mechanism were met satisfactorily by plac-
ing the entire length of the duodenojejunal segment be-
yond the major pancreatic duct at the efferent gastric
outlet. By interposing a short segment of duodenal mu-
cosa between a high ileal segment and the gastric outlet,
it was possible to note when stomal ulcer followed,
whether it occurred in the short duodenal segment or
in the more susceptible high ileal mucosa beyond.

Results. Five of the 12 dogs died of ulcer; in four
of these, perforation was present. All ulcers were stomal
in character, that is, just beyond the gastric outlet on the
afferent loop, save one which occurred in the fundus of
the stomach (dog No. 3). In dog No. 6 the ulcer was
not perforated; death was apparently due to obstruction
of the short afferent loop, an item which probably had
something to do with the occurrence of the ulcer. The
dogs that did not succumb to ulcer were sacrificed at
intervals of 53 to 185 days.

In only one of five dogs (20 per cent) in which the
theoretic quality of the secretin mechanism was good
did a stomal ulcer occur. In three of four dogs (75
per cent) in which it was poor, stomal ulcer occurred.

The Journal Lancet

Experiment /

Shout Afferent Loop and
Efferent Gastroouodenostomy

Lig. of Treitz

Dog

No.

Lcnglh of

Sur-

vivpl

period

Cause Ulcer

Theoretic
secretin
prod iK.

■ ........ %;.A ^

death

autopsy

8 cm.

77 do.

Sacrif,

Good

9 cm.

88 da.

Sacrif.

Good

Experiment 3

Short Afferent Loop, partial duodenojejunectomy.and
Efferent Gastrojejunostomy

Ulcer
Dog 6

<7 Leng'th of

Sur-

Cause

Ulcer

theoretic

$eg. A

£xc. scg.B

period

death

autopsy

10 cm.

75 cm.

61 da.

Sacrif.

Poor

8 cm.

75 cm.

77 da.

Obiaff.L Yes

Poor

Experiment 5

Short Afferent Loop, partial duodenojejunectomy,
Efferent Gastroouodenostomy, and
restoration of continuity by Duooenoileostomy
A

! Sur
vival
period

Cause

death

Ulcer

Lit

autopsy

Theoretic

secretin

produc.

84 da.

Sacrif.

Satis., ?

41 da.

Sacrif

Net

NJtis., 9

Experiment 2

Long Afferent Loop (segment of lower jejunum
interposed between afferent duodenum and stomodi) and

Efferent Gastroduooenosiomy

ileu'm

Dog

No.

Length of

Sur-

viva!

period

Causa Ulcer
of at

death autopsy

Theoretic

secretin

produc.

Seg. A + Seg C

85 cm.

ISO do.

Perit. Yes

Good

85 cm.

185 da.

Sacrif. No

ou,i

Experiment 4

Long Afferent Loop and Gastrojejunostomy

Ulcer
Dogs 7 C &

Dog

No.

Length of

Sur Cause Ulcer theoretic
vivoi of at secretin

period death autopsy produc.

Seg.A

75 cm.

160 da.

ffcrf.uk. Yes Poor

90 cm.

55 da.

Pcrf.ukJ Yes

Poor

Experiment 6

Long Afferent Loop (interposition of lower jejunoileal
segment between afferent duodenum and stomoch), partial
duodenojcjunectomy, Efferent Gastroouodenostomy. an,
restoration of continuity by Duooenoileostoam
B

Dog

No.

Length

of j Sur- : Cau.sc

Scg.A + D

Enc.Sf.ji. period. death

90 cm.

12 cm.

80 cm. 81 da Sacrif.

90 cm.

3 cm.

60 cm. 75do. Pcffulc,

j Ulcer Theorem
i of s*crctin
outov'^v produc

produc .
Good
Nlti> ,

Fig. 4. Types of operation performed in an attempt to separate out the relative importance of the secretin
distance’ and "sensitivity” factors in the role of the long afferent loop in the production of stomal ulcer in
the Billroth II type of gastric resection.

February, 1946

In one of three dogs (33 per cent) in which the quality
of the secretin mechanism was questionably satisfactory
stomal ulcer occurred.

In six dogs in which the spatial factor was satisfactory
(short afferent duodenal loop), stomal ulcer occurred
only once (16.2 per cent). In four of six dogs, in which
the spatial factor was unsatisfactory (long proximal
loop) stomal ulcer occurred four times (66.6 per cent).

In eight dogs the gastric outlet emptied over the duo-
denal mucosa. Stomal ulcer occurred twice (25 per
cent) . In four dogs the gastric outlet met jejunal mu-
cosa. Stomal ulcer occurred three times (75 per cent).

Comment. It is apparent from this analysis that it is
difficult to separate out the eventual role of any single
factor. That is especially true of the secretin and dis-
tance factors. Experiments 10 and 12 constitute an ex-
cellent example of the difficulty (see Fig. 4) . In dog
No. 10 the afferent loop was short; in dog No. 12 it
was long. In dog No. 10 only 4 cm. of duodenal mu-
cosa remained at the efferent outlet for the gastric secre-
tions to glide over in provoking the usual secretin effect;
in dog No. 12 only 3 cm. of duodenal mucosa remained
at the efferent gastric outlet. Spontaneous perforation
of a stomal ulcer killed dog No. 12; 75 days after the
operation no ulcer was present in dog No. 10, when he
was sacrificed at 53 days. In dog No. 10, however, with
the short afferent loop (7 cm.) containing good secretin
containing duodenal mucosa, regurgitation of gastric
secretions into the short afferent loop may have sufficed
to augment the secretin effect of the 4 cm. duodenal
mucosal segment at the efferent gastric outlet. In dog
No. 12, on the contrary, retrograde regurgitation of
gastric secretions into the long 90 cm. afferent loop could
not reach the rich secretin bearing area of the duodenal
segment. This same dog, No. 12, provides a striking
lesson in another respect. The stomal ulcer occurred in
the short (3 cm.) duodenal segment at the efferent
gastric outlet and not in the ileal mucosa just beyond

(Fig- 5);

In this group of experiments stomal ulcer occurred
only once in a dog with a short afferent loop (dog
No. 6) ; in this instance, however, stenosis of the afferent
inlet stoma was present, interfering with delivery of the
alkaline secretions from the duodenal loop. Moreover,
in long afferent loops, in which extraneous factors might
influence the motility of the segment and hence delivery
of the content of the loop, it would appear that such
long afferent loops invite stomal ulcer.

A larger number of experiments in each group would
undoubtedly be helpful in resolving the importance of
each of the factors scrutinized in this study. In addition,
the animals not dying of spontaneous perforation of a
stomal ulcer should be allowed to survive longer before
sacrifice. It is not unlikely that employment of addi-
tional modes of attack may help to separate out more
definitely the component important parts in the predis-
position of stomal ulcer presented by the long afferent
duodenojejunal loop. Three such methods are now be-
ing applied to the problem in this laboratory: (1) assay-

ing the secretin potency of intestinal mucosa from vary-
ing levels of the bowel in both dog and man; (2) deter-

mination of the loss in titratable alkalinity, if any, of
the content of the long afferent duodenojejunal loop as
delivered at the afferent gastrojejunal stoma; (3) experi-
ments in which the sensitivity of the mucosa of various
segments of the intestine is examined by allowing hydro-
chloric acid to drip upon isolated surfaces.

It is difficult to separate out with finality the role of
the various factors contributing to the development of
stomal ulcer attending employment of a long afferent
loop in the operation of complete intragastric drainage
of the content of the duodenal loop. The "secretin”
factor cannot be divorced completely from the consid-
erations of the "distance” factor. Experiment No. 12
(Fig. 4) suggests rather definitely that the "sensitivity”
factor is not as important as the other two factors.

The evidence garnered in this study lends strong con-
firmation to the deductions arrived at in the two studies
listed under A and B, indicating that a long afferent
duodenojejunal loop invites stomal ulcer in any gastric
operation carried out on the Billroth II plan of pro-
cedure.

D. The clinical aspects of the problem of the length
of the afferent loop in gdstric resection for ulcer. The
experimental data described above under captions A, B,
and C suggest definitely that the antecolic anastomosis
with a long proximal duodenojejunal loop, even when
accompanied by an extensive gastric resection, is not a
satisfactory operation for ulcer in man. Man’s small
intestine is approximately twice the length of the small
intestine in the dog. The length of the duodenum in
man is stated by anatomists to vary between 25 and
30 cm. It has been common practice for some gastric
surgeons to make the anastomosis 30 cm. (Balfour, 1935)
or more (Lahey, 1939) beyond the suspensory duodeno-
jejunal ligament of Treitz. Kiefer (1942) has reported
a series of 173 extensive gastric resections for duodenal
ulcer in which the incidence of gastrojejunal ulcer was
11.4 per cent, posited on recurrence verified at opera-
tion, roentgen demonstration of a crater, or the occur-
rence of bleeding. In that series the antecolic long prox-
imal duodenojejunal loop was employed in anastomosis.

In this clinic a series of patients comprising now more
than 400 consecutive gastric resections, all carefully fol-
lowed, has been operated upon for ulcer, employing the
criteria of a satisfactory operation for ulcer described
here. In this group only one stomal ulcer has developed
thus far. In that patient, Mr. L. B., aged 50, an ante-
cedent gastrojejunostomy had been done elsewhere for
a duodenal ulcer. At the operation performed by me
on May 5, 1944, for a gastrojejunal ulcer, only 155 gm.
of tissue were removed including 6 cm. of jejunum.
In the usual three-quarter (75 per cent) resection for
ulcer, the removal of 185 gm. or more is usual. In the
re-operation done on May 2, 1945, 86 additional grams
of stomach were removed, suggesting that at the first
operation the site of the resection was inadequate. A
75 per cent gastric resection, employing a short afferent
duodenojejunal loop with a retrocolic anastomosis made
at or just proximal to the suspensory duodenojejunal liga-
ment of Treitz, has been standard practice in operating
upon patients for ulcer in this clinic for several years.

The Journal Lancet

Fig. 5. Spontaneous perforation of stomal ulcer in dog 12 (Experiment 6, Fig. 4).
The afferent loop was 90 cm. in length, the stomal ulcer occurred in the duodenal seg-
ment. The ''distance” as well as the "secretin” factors were both poor in this experi-
ment. The sensitivity factor was good; in other words, one might reasonably have ex-
pected the ulcer to skio the 3 cm. duodenal segment and to have occurred in the ileum
just beyond, if the ileal mucosa is more sensitive than the duodenal to corrosion by
gastric juice.

E. Would a less extent of excision suffice to protect
against the histamine provoked ulcer if gastric resection
is carried out on the Billroth I plan of operation? 2
Inasmuch as the short afferent duodenojejunal loop is
so important in a satisfactory operation for ulcer, would
it be equally satisfactory to sacrifice less stomach (25 or
50 per cent), but to effect gastrointestinal continuity by
end-to-end suture between the stomach and the duo-
denum by the Billroth I operation? Experiments were
carried out on 12 dogs in three series to attempt to an-
swer this question. Each series had a different amount

of stomach resected, but the residual
gastric pouch in each dog in all series
was anastomosed to the duodenum
just beyond the inverted duodenal end
by means of an end-to-side gastroduo-
denostomy. This procedure, known as
the Billroth I (Haberer-Finney) plan
of operation is technically more feas-
ible in the dog than the straightfor-
ward Billroth I operation, which re-
quires an end-to-end gastroduodenos-
tomy. After an interval averaging 46
days, the administration of 30 mg. of
the histamine-in-beeswax mixture, pre-
pared after the method of Code and
Varco (1940), was injected intramus-
cularly daily. Unless the dogs suc-
cumbed from the complications of
ulcer invoked by the histamine im-
plantation, the injections were carried
out for 45 days.

Results, Series 1. Four dogs were
used. A 25 per cent gastric resection
and gastroduodenostomy was per-
formed at the inverted duodenal end.
After a sufficient period of recovery
from the operation, the daily adminis-
tration of the histamine -in -beeswax
mixture was begun. Three of the
four dogs (75 per cent) developed a
stomal ulcer.

Series 2. The identical procedure
was used on four dogs in this series
with one difference: a 50 per cent

gastric resection was carried out, fol-
lowed after a suitable interval by the
administration of histamine. Stomal
ulcer occurred in three of the four
dogs (75 per cent) .

Series 3. In this series a three-quar-
ter gastric resection (75 per cent) was
done, followed by administration of
histamine. Stomal ulcer did not occur.

These experiments would suggest
that a 75 per cent resection carried
out on the Billroth II plan of opera-
tion, employing a short afferent duo-
denojejunal loop, the anastomosis be-
ing made at the suspensory duodenal
ligament of Treitz, is just as satisfactory an operation
for ulcer as the Billroth I operation.

F. Intractable or incurable recurrent ulcer a myth.
The success with which the three-quarter (75 per cent)
resection has been carried out in the surgical manage-
ment of ulcer suggests that a satisfactory operation has
been found. It is to be admitted freely, however, that
excision of 75 per cent of the stomach is not an ideal
therapeutic measure. It is to be hoped that some day the
same objective may be achieved by less drastic means.
The mortality of the procedure in the experience of this

February, 1946

Fig. 6a. Perforated stomal ulcer in a dog after a 25 per cent gastric resection on the Billroth I opera-
tion. The dog died 17 days after the daily administration of 30 mg. of histamine-in-beeswax was commenced.
Fig. 6b. Large perforating • stomal ulcer in a dog in which a 50 per cent Billroth I resection was done. The
dog was sacrificed 45 days after the administration of histamine was started.

clinic is approximately 2 per cent in gastric resections of
election. The surgical mortality of all procedures for
ulcer, including perforation and hemorrhage, has been
5 per cent. Over a period of more than four years, dur-
ing which we have been assaying the capacity of various
operations to protect against the histamine provoked
ulcer in the laboratory, we have found the Group III
operation (75 per cent resection), here described, uni-
formly resistant to ulcer ordinarily provoked by histamine.
In the single instance in which stomal ulcer has been ob-
served to follow such a resection in a patient, an inade-
quate operation was done. Whereas caffeine and alcohol
are anathema to the patient with an ulcer, we have ob-
served no need to enjoin dietary strictures upon patients
who have undergone the type of procedure described.

Rienhoff (1945), in a recent paper replete with beauti-
ful illustrations, advocates return to a "conservative”
gastric resection for duodenal ulcer, carrying the excision
proximally to include the incisura angularis of the stom-
ach. Rienhoff appends several tables in which he ana-
lyzes his data carefully. His Table III is particularly in-
structive. Of 260 patients operated upon by Rienhoff,
he has found it necessary to subject 29 of the 255 that
survived operation to re-operation, an incidence of 11.3
per cent. If hemorrhage is counted as synonymous with
recurrent ulcer, 21.1 per cent of the survivors have gas-

trojejunal ulcer. In addition, lfi.3 per cent of the sur-
vivors complain of pain. Obviously Rienhoff’s own analy-
sis of the results of his operation may be employed to
suggest that the conservative resection is an inadequate
operation for ulcer. Our own observations suggest that
it is not necessary to excise the ulcer itself in difficult
duodenal ulcers to prevent ulcer recurrence.

Perhaps it is not out of place to point out that the
Billroth II plan of operation abets the ulcer diathesis.1’ ‘
Spontaneous ulcer in dogs is virtually unknown, or at
any rate is a great rarity. However, when gastrojejunos-
tomy is established in dogs an incidence of gastrojejunal
ulcer is observed in 6.6 per cent (Montgomery, 1923) .
If, in addition, pyloric exclusion is performed, gastro-
jejunal ulcer occurs in dogs in approximately 50 per cent
of instances (McMaster, 1934; De Bakey, 1937) , indi-
cating definitely that the Billroth II plan of operation
abets the ulcer diathesis. As a matter of fact, Eiselsberg
(1895) who devised the procedure of combining gastro-
jejunostomy with pyloric exclusion, did it on the basis
of affording complete rest to a duodenal ulcer. Within
a very few years thereafter, however, he observed that
the high incidence of gastrojejunal ulcer following this
procedure (37.5 per cent) warranted its discontinuance.
Wherein lies the explanation of the increased suscepti-
bility to gastrojejunal ulcer following performance of

The Journal Lancet

Fig. 6c. Perforating stomal ulcer in a dog after Billroth II resec-
tion (30 per cent); the dog was moribund from hemorrhage 35
days after administration of histamine was started.

We have been unable to produce stomal ulcer in the dog with
histamine after a three-quarter resection (75 per cent), whether
carried out on the Billroth I or II plan of operation.

gastrojejunostomy combined with pyloric exclusion? I
am inclined to believe it resides in this: that the exclu-
sion of acid gastric juice from the duodenum prevents
normal operation of the hormonal secretin mechanism
described by Bayliss and Starling (1902). In other
words, the small gastric resection is no better and prob-
ably inferior to gastrojejunostomy, which also is a poor
operation with which to combat the ulcer diathesis.

G. Implantation of a pedicled jejunal patch onto the
gastric wall. Andrus and his associates (1943) contend
that a jejunal graft transposed to the gastric wall will
depress gastric secretion; they have employed this pro-
cedure in the therapy of ulcer in man. Grossman and
his associates (1945) from Ivy’s laboratory and Kolouch
and associates (1945) from our laboratory failed to ob-
tain confirmation of Andrus’s contention.

H. Supradiaphragmatic vagotomy. Dragstedt and
Schaefer (1945) report having performed supradiaphrag-
matic section of both vagi nerves in 14 patients with
ulcer with striking improvement. Many of the patients
have been relieved completely of their symptoms. In
three, however, a subsequent gastrojejunostomy became
necessary for the relief of persistent obstruction. We
are now trying to determine whether vagotomy carried
out in this manner in dogs will protect against the his-
tamine provoked ulcer.* It is to be remembered that
whereas vagotomy ablates the cephalic phase of gastric
secretion, vagotomy has been employed to produce ulcer
experimentally. In his Balfour lecture at Toronto, Cush-
ing (1932) considered the neurogenic factor and its rela-
tion to the ulcer problem at length.

Conclusions

The clinical observations and experiments reported
herein appear to justify the following conclusions:

1. The ease of production of perforating gastric
and/or duodenal ulcer in most laboratory animals by the
implantation of histamine-in-beeswax emphasizes the
great importance of the acid-peptic digestive activity of
the gastric juice in ulcer genesis.

2. It is obvious that fat embolism may occur follow-
ing fracture of long bones and plug the end-vessels of
the gastric mucosa and produce erosions and/or ulcer,
which, in turn, in the presence of active gastric secretion
may result in bleeding, hematemesis, and/or melena.
This occurrence has been observed clinically and its coun-
terpart has been produced experimentally.

3. The production of severe bleeding from erosions
and/or ulcer, attending the administration of vasospastic
agents such as epinephrine or pitressin accompanied by
histamine-in-beeswax, definitely suggests the important
role of the ischemia resulting from an overactive vaso-
motor influence in ulcer genesis, when attended by active
gastric secretion.

4. Partial obstruction to the venous outflow from the
stomach increases the weight of the stomach, traceable
to resultant edema of the gastric wall, especially of the
submucosa. Such venous obstruction abets the ulcer di-
athesis. Bleeding gastric and/or duodenal erosions and/or
ulcers, as well as erosions of the lower end of the esoph-
agus, may be produced by such obstructions.

It is suggested that the threatening bleeding of portal
vein obstruction may be corrected by an operation (90
per cent gastric resection) which reduces materially the
capacity of the stomach to secrete. Case records of four
patients in which this procedure has been carried out
are cited. Moreover, it is suggested that occult hemor-
rhage from the alimentary canal frequently has its origin
in the stomach and that gastric resection is indicated as
a therapeutic measure in many such instances. The case
records of four patients in which this procedure was
carried out successfully for profound occult anemia are
cited.

5. The histamine-in-beeswax technique has proved a
useful instrument in appraising the characterization of
a satisfactory operation for ulcer. It would appear that
a three-quarter resection (75 per cent) carried out on
the Billroth II plan of operation, employing a short
afferent duodenal loop in which the antral mucosa and
the lesser curvature of the stomach are excised, meets
the requirements of a satisfactory operation for ulcer.
Our experience with this procedure in patients as well
as in dogs receiving histamine would suggest that the
intractable ulcer may be a myth.

* Experiments completed since this presentation indicate defi-
nitely that in the dog, and even in the rabbit, vagotomy affords no
protection against the histamine provoked ulcer.

References

1. Andrus, W. DeW., Lord, J. W., Jr., and Stefko, P. L.:
Effects of pedicle grafts of jejunum in wall of stomach on gastric
secretion. Trans. Am. Surg. Ass., 61:499, 1943.

la. Babkin, B. P.: Secretory Mechanism of the Digestive

Glands. New York: Hoeber Co., 1944.

2. Baronofsky. I., Lannin, B. G.. Sanchez-Palomera, E., and

Wangensteen, O. H.: Billroth I, gastric resection: extent necessary

to protect against the histamine provoked ulcer. Proc. Soc. Exp.
Biol. & Med., 59:229, 1945.

3. Baronofsky, I., and Wangensteen, O. H.: The experi-

mental production of erosion or ulcer (gastric and/or duodenal) by
the intravenous injection of small amounts of fat in animals. Bull.
Am. Coll. Surg., 30:58, 1945.

4. Idem: Erosion or ulcer (gastric and/or duodenal) experi-

mentally produced through the agency of chronic arterial spasm

February, 1946

invoked by the intramuscular implantation of epinephrine or pitres-
sin in beeswax. Bull. Am. Coll. Surg., 30:59, 1945.

4a. Baronofsky, I., Merendino, K. A., Bratrud, T. E., and
Wangensteen, O. H.: Fate of intravenously injected fat: Its role
in the production of ulcer. Proc. Soc. Exp. Bioi. flu Med., 59:23 1,
1945.

5. Baronofsky, I . and Wangensteen, O. H : Obstruction of

splenic vein increases weight of stomach and predisposes to erosion
or ulcer. Proc. Soc. Exp. Biol. QC Med., 59:234, 1945.

5a. Bayliss, W. M., and Starling, E. H Mechanism of pan-
creatic secretion. J. Phys., 28:325, 1902.

6. Bissell, W. W.: The amount of fat in the blood stream of

persons with broken bones; a preliminary report. J A M. A ,
67:1926, 1939.

7. Boles, R. S., Riggs, H. E., and Griffiths. J. O .: The role
of the circulation in the production of peptic ulcer. Am. J. Dig.
Dis., 6:632, 1939.

8. Brooks, H.: A preliminary study of visceral arteriosclerosis.

Am. J. Med. Sc.. 131:778, 1906.

9. Buday, K.: Uber die Sklerose der Magen Arterien, Zieg-

lers Beitrage, 44:327, 1908.

10. Byrom, F. B. : Morbid effects of vasopressin on the organs

and vessels of rats, J. Path. &C Bact., 45: Pt. I, 1, 1937.

11. Code, C. F., and Varco, R. L : Chronic histamine action,

Proc. Soc. Exp. Biol. & Med., ‘44:475, 1940.

11a. Cushing, H.: Peptic ulcers and the interbrain. Surg.,

Gyn flu Obst., 55:1, 1932.

12. De Bakey, M. E.: The physiology of peptic ulcer. Surg.,

2:653, 1937.

13. Disse: Uber die Blutgefasse der menschlichen magenschleim-
haut besonderen uber die arterien derselben. Arch. f. Mikr. Anat..
63:519, 1904.

14. Dodds, E. C., Noble, R. L., and Smith, E. R : A gastric
lesion produced by an extract of the pituitary gland. The Lancet,
2:918, 1934.

15. Dow, D. R.: Incidence of arteriosclerosis in the arteries

of the body. Brit. M. J., 2:162, 1925.

16. Dragstedt, L. R., and Schafer, P. W.: Removal of the

vagus innervation of the stomach in gastroduodenal ulcer. Surg.,
17:742, 1945.

17. v. Eiselberg, A.: Zur Ausschaltung inoperablen Pylorus-

stenoscn. Arch. f. klin. Chir. 50:919, 1895.

18. Idem: Uber Magen und Duodenalblutungen nach Opera-

tionen. Arch. f. klin. Chir., 59:837, 1899.

19. Enderlen, E., Flotz, G., and Magnus-Alsleben. E.: Die Pa-

thologie und Therapie des Pfortaderverschlusses. Zeitschr. f. d.
Exp. Med., 3:223. 1914.

20. Eppinger, H.: Die Leberkrankheiten. Allgemeine und Spe-

zielle Pathologie und Therapie der Leber. Julius Springer, 1937.

21. Eusterman, G. B., and Balfour. D. C. : The Stomach and
Duodenum. Philadelphia: W. B. Saunders Co., 1935.

22. Fetterman, J. H.: Vascular lesions in surgically excised

stomachs. Arch. Path., 20:189, 1935.

23. Florer, R., and Ochsner, A.: Traumatic chylothorax: report

of a fatal case complicated by a ruptured duodenal ulcer. Surg.,
17:622, 1945.

24. Gallard: Gaz. d. Hopitaux, Nr. 25, 1884. Quoted by
Lewin.

25. Graham, R. R.: Treatment of perforated duodenal ulcers.

Surg., Gyn. 6C Obst., 64:235, 1937.

26. Graves, A. M.: Combined and separate effects of bile, pan-
creatic secretion, and trauma in experimental peptic ulcer. Arch.
Surg., 30:833, 1935.

27. Grossman, M. I., Dutton. D. F., and Ivy, A. C.: An
attempt to confirm the alleged inhibitory effect on gastric secretion
of jejunal pedicle grafts in the wall of the stomach. Surg., 17:685,
1945.

28. Hahn, M., Maaszen, O.. Nencki, M., and Pavlov, J.:
Quoted by Enderlen, Hotz, and Magnus-Alsleben.

29. Hay, L. J., Varco, R. L.. Code, C. F., and Wangensteen,
O. H.: The experimental production of gastric and duodenal ulcers
in laboratory animals by the intramuscular injection of histamine in
beeswax. Surg., Gyn. 6c Obst., 75:170, 1942.

30. Ivy, A. C., and Faulcy, G. B.: Factors concerned in deter-

mining chronicity of ulcers in stomach and upper intestine; suscep-
tibility of jejunum to ulcer formation; effect of diet on healing of
acute gastric ulcer. Am. J. Surg.. 1 1:53 1, 1931.

31. Kesavalu, A., and Mann, F. C. : Influence of duodenal con-
tents on intragastric acidity; experimental study. Surg . 14:578,

1943.

32. Kiefer, E. D.: Jejunal ulcers and recurrent hemorrhages

after partial and subtotal gastrectomy for peptic ulcer J.A.M.A .
120:819. 1942.

3 3. Kolouch, F., Jr.: A direct visual technique for studying

chemical injury to exposed mucosal surfaces. Surg., 17:641, 1945.

34. Kolouch, F., Jr., Castellanos-Moreno, M., Dubus, A. T. S.,

Baronofsky, I., and Wangensteen, O. H.: III. Mechanism of

stomal ulcer is related to length of afferent duodeno- jejunal loop.
Proc. Soc. Exp. Biol. Qc Med., 58:275, 1945.

35. Kolouch, F., Jr., Dubus, A. T. S., and Wangensteen. O.

H.: The pedicled jejunal transplant on to the gastric wall. Surg.,

17:667, 1945.

36. Lahey, F. H., and Marshall, S. F.: Technique of subtotal

gastrectomy for ulcer. Surg., Gyn. 6c Obst., 69:498. 1939 (in
legend of Fig. 14).

37. Lannin, B. G.: Experimental evaluation of a satisfactory

operation for ulcer. Surg., 17:712, 1945.

38. Lannin, B. G., Hay, L. J., Judd, E. S , and Wangensteen,

O. H.: Evaluation of a satisfactory operation for ulcer. Proc. Soc.

Exp. Biol. Qc Med., 56:231, 1944.

39. L-? Count, E. R., and Gauss, H.: A study of fat embolism

associated with fracture. Trans. Chicago Path. Soc., 9:251, 1915.

40. Lewin, A. M.: Zur Lehre der arieriosklerose des Magens.

Arch. f. Verdauung, 14:1 14, 1908.

41. Maier, H. C., and Grossman, A.: Relation of duodenal
regurgitation to the development of jejunal ulcers. Surg., 2:265,
1937.

42. Mann, F. C., and Williamson, C. S.: The experimental
production of peptic ulcer. Ann. Surg., 77:409, 1923.

43. Matthews, W. B., and Dragstedt, L. R.: The etiology of

gastric and duodenal ulcer. Surg., Gyn. fie Obst., 55:265, 1932.

44. McCann, J C.: Experimental peptic ulcer. Arch. Surg.,
19:600, 1929.

45. McKittrick, L. S.. Moore, F. D , and Warren, R.: Compli-

cations and mortality in subtotal gastrectomy for duodenal ulcer.
Report on a two-stage procedure. Trans. Am. Surg. Ass., 62:53 1,

1944.

46. McMaster, P. E.: Effect of diverting the gastric contents

to the lower intestinal levels. Arch. Surg., 28:825, 1934.

47. Merendino, K. A., Varco, R. L., Litow, S. S., Kolpuch, F.,
Jr., Baronofsky, I., and Wangensteen, O. H.: I. Stomal ulcer
attending complete intragastric regurgitation as influenced by length
of afferent duodenal-jejunal loop. Proc. Soc. Exp. Biol. 6c Med.,
58:22, 1945.

48. Merendino, K. A., Lannin, B. G., Kolouch, F., Jr., Baro-
nofsky, I., Litow, S. S., and Wangensteen, O. H.: II. Length of

afferent duodenojejunal loop in gastric resection, a factor in stomal
ulcer. Proc. Soc. Exp. Biol. fiC Med.', 58:226, 1945.

49. Merendino, K. A., Litow, S. S., Armstrong, W. D., and

Wangensteen, O. H.: The experimental production of erosions or

ulcer (gastric and/or duodenal) in animals by fracture of curette-
ment of bone marrow. Bull. Am. Coll. Surg., 30:58, 1945.

50. Merendino, K. A., Litow, S. S., and Wangensteen, O. H.:
Failure of fracture or curettement of the marrow of long bones in
dogs or fracture in man to cause stimulation eff gastric secretion.
Bull. Am. Coll. Surg.. 30:58, 1945.

51. Montgomery, A. H.: Gastrojejunal ulcer; an experimental

study. Arch. Surg., 6:136, 1923.

52. Nedzel, A. J.: Experimental gastric ulcer (pitressin epi-

sodes). Arch. Path., 26:988, 1938.

53. Ogilvie, W. H.: Approach to gastric surgery: ulcer of

the stomach. The Lancet, 2:295, 1938.

54. Ophuls, W.: The relation of gastric and duodenal ulcer to

vascular lesions. Arch. Int. Med., 1 1:469, 1913.

55. Orndorff, J., Bergh, G. S., and Ivy, A. C. : "Peptic” ulcer
and "anxiety complex”; failure of pharmacologically sustained
hypersecretion and hypermorility of stomach to produce chronic
gastric ulcer in dogs. Surg., Gyn. flu Obst., 61:162, 1935.

56. Payr, E.: Experiment uber Magenveranderungen als Folge

von Thrombose und Embolie in Pfortadergebrete. Arch. f. klin.
Chir., 84:798. 1907.

5 7. Idem: Beitrage zur pathogenese. Pathologischen Anatomie
und radicalen operatien Therapie des runden Magengeschwiirs.
Ibid.: 93:436, 1910.

58. Pearse, H. E.: Experimental studies on the gradual occlu-

sion of large arteries. Trans. Am. Surg. Ass., 58: 443, 1940.

59. Rienhoff, W. F.: An analysis of the results of the surgical

treatment of 200 consecutive cases of chronic peptic ulcer of the
duodenum. Ann. Surg., 1 21:583, 1945.

60. Schmilinsky, H.: Die Einleitung der gesamten Duodenal-

safte in den Magen (inner Apotheke). Centralbl. f. Chir., 45:416,
1918.

61. Schmorl: Discussion of Sternberg’s paper, p. 2 36.

62. Schridde: Discussion of Sternberg’s paper, p. 2 34

63. Schwyzer, F.: Eructation in heart patients. New York

Med. J.. 85:625, 1907.

64. Sternberg, C.: Experimentell erzeugte Magen geschwure bei

Meerschweinchen. Verhandl. d. deutsch Path. Gesellsch., 1 1:232,
1 907.

65. Wangensteen, O. H.: Discussion on mediastinitis, Trans.

Am. Surg. Assn., 56:129, 1938.

66. Idem: The controlled administration of fluid to surgical

patients; including description of gravimetric methods of determin-
ing status of hydration and blood loss during operation. Minne
sota Med.. 25:783, 1942.

67. Idem: The surgical management of ulcer (a chemical prob-
lem, including description of how the secretin factor influences the
success of anastomotic procedures). Med. Record 6>C Ann., 37:575,
1 943.

68. Wangensteen, O. H., and Lannin, B. G.: Criteria of an

acceptable operation for ulcer; the importance of the acid factor.
Arch. Surg., 44:489, 1942.

69. Wangensteen, O. H., Merendino, K. A . and Litow, S. S.:
Hematemesis from erosion or ulcer (gastric and/or duodenal); an
occasional complication of fracture. Bull. Am. Coll. Surg., 30:58,

1945.

70. Wangensteen, O. H., Varco, R. L., Hay, L. J., Walpole.

S., and Trach, B. : Gastric acidity before and after operative pro-

cedure with special reference to the role of the pylorus and an-
trum; a preliminary report of a clinical and experimental study.
Ann. Surg., 1 12:626, 1940.

71. Weiss, A. S., Graves, A., and Gurriaran, G.: La derivation

intragastrique des sues alcalins duodenaux. Compt. rend. Soc. de
biol., 109:916, 1932.

72. Whipple, A. O.: The problem of portal hypertension in

relation to hepato-splenopathies, E. Starr Judd Lecture, University
of Minnesota, April 10, 1945.

73. Whipple, G. H., Robscheit-Robbins, F. S., and Hawkins,
W. B.: Eck fistula liver subnormal in producing hemoglobin and
plasma proteins on diets rich in liver and iron. J. Exper. Med.,
81:171, 1945.

74. Wilkie, D. P. D.: Retrograde venous embolism as a cause

of acute gastric and duodenal ulcer. Edinburgh Med. J., 6:391,
1911.

The Journal Lancet

A High Fluid Intake Regime in tht^'fosfoty5
Management of Edema

A Review with Some Comments after Four Year

F. R. Schemm, M.D., F.A.C.P.

Great Falls, Montana

ABOUT four years ago a formal report 1 of ob-
servations on a regime in which large amounts
L of water were given to patients suffering from
dropsy was published. Within a year after publication
of the 1942 report a few workers who had carefully
followed the details of the regime had confirmed the
observations made.J

These observations were as follows. With the proper
regulation of sodium ingestion large amounts of water
can be given to patients with dropsy, not only with im-
punity but to their benefit. The theoretical objections to
such a regime in "brine-logged” patients do not, in fact,
hold up against bedside observations. The immediate
and later results of the high fluid intake regime are
superior to those obtainable with the accepted restricted
fluid regimes.

In this paper the details of the regime are again re-
viewed, together with the reasons for its failure to clear
edema in some cases, and some rather common miscon-
ceptions regarding the regime are discussed, for, as Sir
George Baker put it many years ago, "I much wish to
see an indulgence of this kind extended to poor thirsty
dropsical patients.”

Review of the Details of the Regime
This regime, in brief, adds to a diet and certain im-
portant precautions, designed to avoid the ingestion of
any excess of basic ash, the advantages of acid drugs
used for over two hundred years, the liberal amounts of
water often given up to a hundred years ago, and the
salt restriction in vogue during the past fifty years.

The regime provides enough water for all the needs
of the body, while properly regulating or manipulating
sodium ingestion. It is based on a correlation of water
balance, renal function, body fluid, and acid-base equi-
librium studies. Figure I brings together a few facts
that help to define what is meant by "enough water” and
shows under what conditions enough water may reach
the kidneys to permit them to eliminate sodium. Sodium
salts actually presented even to badly damaged kidneys
are readily excreted if enough water reaches the kidneys
at the same time. A diversion of water from the kidneys,
for normal and abnormal needs of the body, is thought
to be chiefly responsible for a suppression of urine.

In Figure 1 the black lines to the left (with Roman
numerals) , show what may be the fate of ingested water
before any can reach the kidneys. Thus (line I) for
temperature regulation alone the vaporization of water
from the lungs and skin may take from 800 to 5000 cc.
There may be (line II) a pre-existing true dehydration,
or plain water deficit. This condition is frequently pres-

From the Medical Department of the Great Falls Clinic, Great
Falls, Montana.

Read at the meeting of the Wyandotte County Medical Society,
Kansas City, October 19, 1945.

ent in seriously ill edematous patients. Such patients are
so often thirsty, and are not "water-logged,” but actually
brine-logged. The correction of this water deficit may
require water amounting to as much as 6 to 10 per cent
of the body weight, or as much as 6000 cc. Some non-
edematous patients (line III) must be given much water
with salt before any water is available to the kidneys.
When an excess of sodium salts is being retained (line
IV), or, in other words, when edema is forming, one
liter of water is diverted as solvent for every 9 grams
of the alkaline salt mixture. These first four lines indi-
cate roughly why it is essential to give enough (or, when
in doubt, more than enough) water to provide for vapor
loss and pre-existing dehydration, and why it is impor-
tant to regulate sodium ingestion to avoid the diversion
of water to edema formation. Finally (line V), enough
extra water must get through to the kidneys to permit
them to do their work. Renal function studies show that
to excrete solids presented to them, badly damaged kid-
neys may require four to five times as much water as
normal kidneys. Therefore, at times it is essential to
provide for around 2000 cc. of urine water over and
above the prior demands of the body. In health a nor-
mal water balance may be maintained with as little as
1500 cc. of water daily, but in a badly dehydrated edema-
tous patient, with fever or sweating and badly impaired
kidneys, the water requirement may amount to 6 to 8
liters for a day or two and from 4 to 5 liters daily there-
after. An average of 2 to 3 liters daily is enough, and
safe, only for the average mild case. A faulty regulation
of sodium ingestion while forcing fluids will, as shown
in line IV, divert what otherwise might be enough water
into the marshland of the interstitial space.

The large amounts of water given in this regime can
be given effectively and safely only if sodium ingestion
is properly regulated. This regulation is achieved by the
use of so-called neutral diets and by taking some very
necessary precautions to avoid any extradietary ingestion
of salt, sodium, or basic-ash excess, which would defeat
the effect of the diet. Acid-base equilibrium studies indi-
cate that a slight excess of basic ash is essential to the
accumulation of the sodium salts of the edema fluid and
that the mobilization and elimination of these salts are
accomplished physiologically by the metabolic acids.
These acids use up the bicarbonate fracrion of the accu-
mulated sodium salts and, by threatening mild acidosis,
incite the kidneys to eliminate the neutral or slightly acid
sodium salts passing through them.

The diet and precautions of the regime are designed
to prevent any interference with this physiological process
and to augment its action. Table 1 gives skeleton out-
lines of the diets commonly used. Each feeding or meal

February, 1946

WAT efc

VAPOR,

. 1 3

URINE

Fig. 1 . Showing conditions under which enough water reaches
kidneys to permit them to eliminate sodium.

is so balanced as to yield a neutral ash or a slight excess
of acid ash. Construction of the diets depends on our
knowledge that milk and saps of all vegetables and of
all fruits, except prunes, plums, and cranberries, yield an
excess of basic ash. The full neutral diet shown in
Table 1 can be used indefinitely. Diabetic, ulcer, and
reduction diets can be constructed around it. The middle
of the table shows the six small feedings of the initial
neutral diet — soft type of diet, quite like the old Karrel
diet at the point where cereal, toast, and eggs were
started, except that salt is restricted. The diet can be
as simple as the old bread and rtrilk diet, and it is sug-
gested by these outlines that the commonly used dry
or high protein diets probably achieve an excess of acid
ash by the proportionately greater amounts of cereals
or proteins used.

The four precautions listed at the bottom of Table 1
are only a few of the more obvious ones that experience
has compelled us to formulate. "Fancy” foods refer to
salt-cured meats and cheeses, relishes, salted nuts, etc.
"Vegetable” salts, such as EKA salt, are all sodium salts
of some vegetable acid, and quite as undesirable as
sodium chloride. Ammonium chloride or potassium
chloride is prescribed as a salt substitute. Similarly, such
commercial alkalies as "Turns,” and bicarbonate of soda
for indigestion are specifically forbidden and calcium
carbonate or aluminum hydroxide is prescribed. The
fourth precaution emphasizes the fact that such extra
fluids as citrus fruit juices, milk, or salty bouillon, given
so frequently, have a disastrous effect. Small amounts of
plum, prune, or cranberry juice are added to flavor the
water; synthetic flavorings such as "Koolade” are used to
avoid the natural basic-ash laden saps of the other fruits;
or unsalted broths are given; or, in the case of children,
the extra milk is given partly neutralized with 10 to 15
drops of diluted hydrochloric acid. If avitaminosis is
feared, vitamin concentrates can be given.

The precaution against salt in the cooking is relaxed
in milder cases and in patients who are anorexic, because,
within limits, the total amount of salt is of less impor-
tance than the net diet reaction.

A fifth precaution is so obvious that it is often over-
looked. It is necessitated by the fact that the patient
may habitually select and actually eat only the basic-ash
elements of a perfectly prepared neutral diet. So the
patient is instructed to eat all of each feeding, or, if an
acid-ash item is not eaten, to deduct from the tray an
equivalent amount of basic ash.

These precautions are aimed at the inadvertent addi-
tion of salt, sodium, and basic-ash liquids or foods. They
emphasize that this diet is not simply a low-salt or a low-
sodium or an acid-ash diet, but is, if effective, a combi-
nation of all three. Thus others have used, and found
wanting, diets with only one fourth the amount of
sodium chloride but without an excess of acid ash, and
some have used strongly acid-ash diets without a proper
restriction of sodium or salt and found them ineffective.

Each precaution added to the regime in the course of
our experience has its story. As an example let me cite
the case of a man whose ascites had required frequent
paracenteses and who became free of edema and ascites
on the regime. His wife, an intelligent and intense uni-
versity graduate, was so enthusiastic that she mastered
the diet, bought the acid-base food tables, improved on
our diet, and carried the patient edema free for a year
and a half. He returned then with a massive reaccumu-
lation of his edema and ascites six weeks after adding,
to the strictly followed high fluid regime, half a water-
melon daily, which his alert wife had read was a cure
for hypertension. The basic-ash excess of its sap had
overpowered the effect of the regime. When the water-
melon therapy was discontinued the regime was again
entirely effective.

Earlier, a young man whose resistant nephrotic edema
had responded to the regime in a most gratifying man-
ner, and whose wife had mastered the regime, returned
in two weeks with a recurrence of 20 pounds of edema
because he had not been forbidden to use soda for in-
digestion. Calcium carbonate was substituted for the
sodium bicarbonate and without further change he again
became edema free.

Other observations emphasize the necessity of taking
steps to provide enough water to permit the kidneys to
rid the body of the excess sodium presented to them.
Thus on numerous occasions, particularly in patients
with impaired renal function, edema has not cleared,
even with the most perfect regulation of sodium, until
an intake of from 2 to 3 liters daily was increased to
4 to 5 liters daily in order to provide a very large amount
of urine water.

Table 2 gives an example of hospital orders intended
to institute the regime in a moderately severe to severe
case. The nursing and dietetic staffs are assumed to be
reasonably familiar with the regime and its precautions,
and it is assumed that suitable orders have already been
given to cover the primary disease, such as orders for
oxygen, digitalis, and sedation when indicated. The
initial neutral diet, with its six small feedings, is a suit-
able soft cardiac diet. The desirable fluid intake was
thought to be 4000 cc. daily in this case. Small amounts
of diluted hydrochloric acid and ammonium chloride
were ordered to augment the effect of the acid-ash excess

The Journal Lancet

Table 1

Outlines for Neutral Diets

FULL NEUTRAL

Limited Base r

s. Acid No Limit

24-hour Minimum

1 pint

Milk

Eggs

2 servings

Vegetables

Meat, fish, fowl

1 serving

2 servings

Fruits except prune, plum, cranberry

Bread or cereals

5 slices or servings as desired

INITIAL NEUTRAL

6 Cups 6 Small Feedings j Minimum: One Item per Cup

6 servings

Milk or

Egg or

Milk and
cream Vi

Bread or

2 slices

Cereal prepared or cooked

1 cup

1. No salt or soda in or on food. 3. No "vegetable” salt; no soda for "gas”.

2. No "fancy” foods put up with salt. 4. No salt broth, or extra juices, or milk.

of the diet. The diluted hydrochloric acid can be given
when a patient can take only liquids orally. When given
every hour in 5-drop doses, as here ordered, it helps to
bring up the oral intake. Note that the amount of am-
monium chloride, 3 grams daily, is less than the 6 to 9
grams recommended on restricted fluid regimes. The
first four orders shown in Table 2 are usually adequate
to cover the average case, when the patient is not too
sick to eat the diet or to take the prescribed amount of
water orally.

The intravenous supplements are given only when it is
necessary to augment the oral intake. Five per cent dex-
trose is used in distilled water (not in normal saline
with its 9 grams of salt per liter) in the amounts indi-
cated in Table 2.

In the more severely ill patients mercupurin is used
to speed the elimination of sodium. In our experience
its diuretic action is greatly enhanced by the high fluid
regime, with smaller and fewer doses necessary, and post-
diuretic dehydration and shock are rare.

Failure of the Regime to Clear Edema

In the last few years we have studied rather closely
the reasons for the failure of the regime to clear edema
in any given case.

Of course there are cases, as Landis suggested in a
personal communication, that do not benefit simply be-
cause the regime is stopped when the initial rehydration
weight gain, with a perceptible edema increase, is seen in
the first day or two. Such a reaction may be frightening
in the case of the more seriously ill, "brine-logged” pa-
tients with large plain water deficits. As shown in Fig-
ure 2, the correction of true dehydration follows the
same pattern in nonedematous and edematous patients.
All show the initial discrepancy between intake and out-
put. The edematous show a perceptible increase in edema,
but at the same time, as their thirsty cells are satisfied
they usually show an encouraging clinical improvement
(as indicated by the arrows), which often occurs well
before the onset of diuresis and the clearing of edema.
Diuresis and disappearance of edema are the usual re-

ward for persisting with the regime, even in some very
unpromising cases. Figure 2 also shows that, despite
differences in the primary disease, the response of edema
to the regime is the same in nephritis, eclampsia, and
heart disease.

Analysis of failures experienced elsewhere by others —
and some of these cases subsequently responded well in
our hands — shows, when sufficient data are available,
that the failures fall chiefly into two groups. In the first
group some detail of the regime had been overlooked or
neglected, even though orders were given to restrict salt,
give a neutral diet, and provide an adequate total fluid
intake. For instance, intravenous supplements to the in-
take had been given as 5 per cent dextrose in normal
saline solution, rather than in distilled water, or an excess
of basic ash had found its way to the patient from extra
portions of citrus fruit juice or milk, or from sodium
medication, or the patient had actually been eating only
the basic-ash foods of his diet.

In the second group failure had occurred when every
detail of the regime had been properly enforced, and
appeared to be due to inadequate management of the

Table 2

An Example of Hospital Orders

1. Diet "Initial Neutral” (6 small feedings).

2. Fluid Intake to 4000 cc. daily.

3. Diluted HC1 Vi cc. in a glassful of water every hour
from 8 a.m. to 7 p.m.

4. Ammonium Chloride 0.5 grams after feedings, or
1 .0 grams t. i. d.

5. 500—1000 cc. of 5 °/o Dextrose in distilled water by
vein (8 A.M., 2 P.M., 6 p.m., when needed to bring
total intake to 4000 cc.)

6. Mercupurin 1 cc. in 500-1000 5 % Dextrose in dis-
tilled water by vein (when needed, but not before
one full day on regime) .

7. Record 24-hour intake and output, and weigh daily
before breakfast.

February, 1946

WATER, DEFICIT OLIGUPJA

Fig. 2. Showing that the correction of true dehydration follows
the same pattern in nonedematous and edematous patients.

primary disease. In these cases, for example, the regime
had been relied on to replace adequate digitalization, oxy-
gen therapy, or occasional doses of mercurial diuretics,
when these measures were badly needed.

On our own services, where the personnel in nursing
and dietetics have had careful training in the details of
the regime, the failures seem to be confined to cases with
advanced terminal disease. Such patients may have
severe cerebral involvement or a semistupor with marked
uremia, or, at autopsy, are shown to have multiple pul
monary infarctions.

Misconceptions Regarding the Regime

From both direct and indirect correspondence it is
evident that misconceptions have arisen about some im-
portant points of the regime, which may lead to some
unnecessary failures. They may be attributed chiefly to
imperfections in the original report 1 of the details and
basis of the regime, and perhaps occasionally to a not
too close reading of the original article.

Some minor misconceptions are expressed in a favor-
able critical estimate of the regime under "Minor Notes”
in the Journal of the American Medical Association for
June 9, 1945, where it is stated that 2 to 3 liters of
water daily are sufficient. Such an amount is sufficient
in most cases, but it should be emphasized that in the
more seriously ill patients, with high water vapor loss or
very poor renal function or a large water deficit, there
will be no response unless 4 to 6 liters daily are given,
sometimes for many days. Sir George Baker emphasized
this fact in 1772, when he said: "Indulge the patient to
the utmost. A limited permission may be pernicious.”
The review states that considerable amounts, from 3 to 9
grams daily, of ammonium chloride, are given. Actually,
in our series the usual dosage of ammonium chloride
was I/2 to 4 grams daily, with a rare maximum of 6
grams daily. On the basis of renal function studies it is
desirable to decrease the total solids to be eliminated;
hence these smaller amounts of ammonium chloride are
preferable. For the same reason the use of diluted hydro-
chloric acid is desirable. The article goes on to suggest
that the hydrochloric acid is not necessary or effective,

yet we have found it indispensable in the very sick, who
at first do not tolerate solid food or the solid salt of
ammonium chloride. Finally, the article states that it is
the production of acidosis that leads to the diuresis, and
hence there is a limitation in the usefulness of the regime
where renal insufficiency exists. On the contrary, the
small dosage of acid drugs actually used to supplement
the action of normal metabolic acids and the large
amounts of water provided at the same time help badly
damaged kidneys to regulate body-fluid composition and
to respond more quickly to the mere threat of acidosis,
while large doses of acid drugs with restricted intake
may induce a very severe acidosis. Actually, the regime
was developed from one used in nephritic edema.

One objection raised to the regime by others has been
the difficulty of getting the patient to eat a diet so low
in salt. In two recent publications it has been stated
erroneously that we use a diet yielding only half a gram
of salt daily. Such a diet was used by Schroeder, but
the strictest of our diets uses four times as much salt,
or a little over 2 grams. It is not impracticable to con-
struct a diet with this amount of salt, and if salt substi-
tutes do not relieve harmful anorexia we permit a little
more salt, which does no harm if the diet reaction is acid.
There are always patients who will not abide by any diet,
whether it be an obesity, an ulcer, a diabetic, or a neu-
tral diet, just as there are diabetics who refuse insulin,
ulcer patients who smoke, and pernicious anemia patients
who neglect their liver extract. Our own congestive heart
failure veterans seem to prefer this regime, in spite of
its flat diet.

One commentator remarks that the regime depends
simply on the large intake of water "washing out” so-
dium. Another says that the water will not wash out
sodium, that forcing fluids is therefore not beneficial,
and that simple salt restriction will result in diuresis and
clearing of edema and is all that is necesasry. Our data “
show clearly that the water does not "wash out” sodium;
the water appears only to remove that sodium which is
mobilized by acidification and is presented to the kid-
neys. On the other hand, acidification without adequate
water gives only acidosis and dehydration. Simple salt
restriction, though useful, is, of course, as inadequate
alone as it has been for fifty years.

One hundred and fifty years ago large amounts of
water were given without salt restriction, and for the
last fifty years salt has been restricted without an ade-
quate supply of water. Heavy doses of acid diuretics
were used in both eras. What we have shown is that the
dropsical patient can indulge in large amounts of water,
safely and beneficially, if salt is reasonably restricted
and if the gentle physiological effect of metabolic acids
in mobilizing sodium is not retarded by an excess of
basic ash or is augmented by a "neutral” diet and small
amounts of acid drugs.

Other communications suggest that cases with con-
gestive heart failure and cases with nephritis could not
respond in the same manner to the regime because of
differences in renal blood flow and filtration rates. So
far as therapy is concerned this is a misconception, due,
probably, to narrow fields of interest. Before this study

The Journal Lancet

was begun in 1933 we were discouraged by some of our
teachers who thought that what worked for nephritic
edema, as shown by Newburgh, could not possibly work
for cardiac edema, because of the theoretical differences
in their mechanisms of edema formation. Yet now some
who have found this regime to work in cardiac dropsy
are of the opinion, on hypothetical grounds, that it could
not work in nephrosis or nephritis with edema. In our
hands the regime has, in fact, been effective in cardiac
and renal disease and in eclampsia, as shown in Figure 2,
and has been useful in cirrhosis and in any condition
where edema, oliguria, or dehydration was encountered. -
One of our most prized letters, from an Army hospital
in France, states that the regime was proving most useful
in "avoiding or relieving a suppression of urine in battle
casualties with severe injuries or serious infections.” It
would appear that water balance principles, which sur-
geons have used so well and which we in internal medi-
cine have been so slow to exploit, can be made more

effective by the addition of principles derived from
sodium and acid-base balance studies from medicine,
pediatrics, and obstetrics. Certainly the derivations of
this high fluid regime, and we believe its usefulness, are
not limited to one branch of medicine or to one division
of internal medicine.

Summary

1. Some details of a regime which enforces a high
fluid intake and regulates sodium ingestion in the man-
agement of edema are briefly reviewed.

2. Some reasons for failure of the regime and some
misconceptions regarding it which have arisen in the four
years since the original reports are discussed.

References

1. Schemm, F. R.: A High Fluid Intake in the Management
of Edema, Especially Cardiac Edema. I. The Details and
Basis of the Regime. Ann. Int. Med., 17, 952-69, 1942.

2. Ibid.: II. Clinical Observations and Data. Ann. Int. Med.,
21, 937-76, 1944.

BIOLOGICAL ASPECTS OF MORPHINE ADDICTION

A recent number of Public Health Reports* describes a longitudinal study of the prob-
lem of drug addiction. The subjects were two "post-addicts” serving sentences for violations
of the Harrison Narcotic Act, and chosen because their sentences were sufficiently long to
permit prolonged investigation and adequate time for recovery, because they had long his-
tories of addiction, and because they showed promise of active and continued cooperation in
the experiment.

Over a period of two years a study was made of the cycle of addiction, including pre-
liminary tests to establish norms for the two subjects, administration of morphine in increas-
ing doses, rapid withdrawal of morphine, and recovery. The recovery period was divided
into five parts to show progressive changes.

The aspects studied included the intake of carbohydrates, fat, protein, and water, and
an analysis of urine and feces during the corresponding periods. Clinical observations includ-
ed temperature, blood pressure, pulse, and respiration. Nocturnal activity was determined by
recording the number and magnitude of movements the patient made in bed. Basal metab-
olism determinations were made, blood was analyzed, and body hydration was determined.

The results indicate that morphine addiction is accompanied by: increases in body water,
water content of blood, blood sedimentation, carbohydrate intake, and nocturnal activity; and
by decreases in body weight, hemoglobin, packed cell volume, pulse rate, basal metabolism,
and diastolic blood pressure.

A study of the acute effects of morphine showed that the minute volume of respired air,
respiratory quotient, and insensible water loss were usually decreased after morphine, espe-
cially after large doses; that the basal metabolic rate was decreased after large doses, and the
blood was slightly more concentrated after morphine. There was no indication that addic-
tion alters the action of the drug.

•Vol. 61, No. 1, January 4, 1946.

February, 1946

Chronic Unstable Colon

Dalton M. Welty, Captain, M.C.A.U.S.

Hot Springs, South Dakota

I HAVE chosen to talk about the unstable colon, not
so much because of its intrinsic interest as because of
its everyday importance in the practice of medicine.
The unstable colon has had a great many other names
— spastic colon, irritable colon, chronic colitis, and spastic
colitis — -but I believe the term "unstable colon” describes
the condition most accurately. The unstable colon is not
always or uniformly spastic. The term "colitis” connotes
infection to the doctor, and frequently to the patient as
well. Irritability is a characteristic of all living tissue.

The patient with an unstable colon nearly always com-
plains of dull, aching abdominal pain. He has had it
a long time — 65 per cent longer than five years, 38 per
cent longer than fifteen years. Often the pain shifts
from week to week, but most often it is localized in the
right lower or right upper quadrant of the abdomen.
Sometimes it is mainly in the left abdomen. It may be
associated with constipation, diarrhea, or regularity.
Sometimes constipation alternates with diarrhea. The
patient will state that his pain is considerably helped or
entirely relieved by the passage of gas or a good bowel
movement. Some superimposed, crampy pain may be
present just before the passage of gas or stool. The
color of the stool is normal, but it may be small in cali-
ber, with chopped off ends, or of the "sheep dung” type.
At any event the patient usually says the stools are un-
satisfactory for one reason or another. Sometimes a little
mucus, which the patient may confuse with worms, is
present. The patient may have slight nausea with belch-
ing. Vomiting is uncommon. Physical examination of
the abdomen reveals little. There may be tenderness
along the course of the colon, especially the descending
colon. It may be felt as a firm cord — the "garden hose”
type of colon. Gurgling on deep pressure over the cecum
is common. Sometimes the rectal sphincter is spastic.

We can write our findings in two lines. The history
will take a page. Laboratory examinations are usually
negative. But here a red herring may appear, such as
slight hyperchlorhydria or hypochlcrhydria or a diver-
ticulum somewhere. Possibly the gallbladder may empty
a bit sluggishly. The complaints are indeed out of pro-
portion to the physical findings. We are dealing with
disturbed physiology without demonstrable anatomical
or pathological component. Our attention is directed to
neuromuscular mechanism of the large bowel in an
effort to understand the nature of this malady.

The smooth musculature of the large bowel has a dual
innervation through both sympathetic and parasympa-
thetic nerves. The sympathetic fibers, with cells of
origin in the thoracolumbar cord, course through the
thoracolumbar sympathetic chain to synapse with cells
in the superior mesenteric plexus. From this plexus
axones extend to reach the ascending and approximately

Read before the Black Hills District Medical Society, Deadwood,
South Dakota, November 29, 1945.

half the transverse colon. The remainder of the distal
colon receives its sympathetic innervation from the sec-
ond and third lumbar segments of the cord, via the lum-
bar splanchnics, to form the inferior mesenteric and then
the presacral nerve. Stimulation of the sympathetic
nerves to the colon causes relaxation of tone and contrac-
tion of the internal anal sphincter. Section of this in-
nervation increases tone and causes relaxation of the
internal anal sphincter. In other words, the sympathetic
nerve supply exerts a constant inhibitory action on the
colon.

The parasympathetic fibers course through the vagus
nerve to innervate the proximal colon and through the
second, third, and fourth sacral nerves to innervate the
distal colon. Stimulation of the parasympathetic supply
causes an increase in tone of the colon and relaxation of
the internal anal sphintcer. In general, sympathetic
stimulation causes constipation and parasympathetic stim-
ulation favors evacuation.

Gradually a better understanding of colon motility is
being gained. Atkinson, Adler, and Ivy of the Depart-
ment of Physiology and Pharmacology of Northwestern
University have contributed a great deal by means of
their careful work in studying colon motility in dogs
and human beings with colostomies, by means of tandem
balloons. They have found motor activity of some kind
occurring in the colon 50 per cent of the time. Only
10 per cent of this activity is propulsive. The remainder
is local, segmental, and nonpropulsive. Nonpropulsive
contractions, responsible for maintenance of tone, occur
normally three to eight times per minute. Contractions
of larger amplitude occur irregularly, and propulsion
occurs when these larger contractions become coordinated
with similar contractions in a distal segment. Coordina-
tion of many segments occurs two or three times daily,
usually after meals — the so-called gastrocolic reflex. Each
segment of the colon for contraction purposes is about
5 cm. long. Pain will occur when a strong propulsive
wave meets a distal segment manifesting marked non-
propulsive activity (increased tone). Thus functional
obstruction may occur. It is possible for liquid bowel
contents to pass such a zone of increased nonpropulsive
activity. Material of more solid consistency will act as
a plug.

Much effort has been expended to find a satisfactory
drug that will abolish excessive nonpropulsive activity,
but no completely satisfactory one has been found. Atro-
pine will lessen nonpropulsive contraction and completely
abolish propulsive activity for about two hours. Trasen-
tin (diphenyl diethylaminoethanol hydrochloride) in-
hibits tone almost as well as atropine, probably as a direct
action on smooth muscle. Under trasentin influence the
activity of the various segments is more uniform and
coordination between segments is improved. Given
orally, it produces a decrease of about 35 per cent in

■56

The Journal Lancet

total motility. Spasmalgin (a combination of papaverine,
pantopon, and an atropine ester) produces increased
tone but abolishes propulsive activity. Benzedrine, octin
(methyloctenylamine hydrochloride), and syntropan pro-
duce little discernible effect experimentally, according to
Ivy and his associates. Morphine definitely increases
tone, and then no oral antispasmodic is effective. Tra-
sentin and morphine are incompatible. Together they
invariably produce nausea and malaise.

The best available antispasmodic drugs are atropine
and trasentin. Atropine is slightly more potent in less-
ening nonpropulsive activity, but trasentin improves the
functional gradient more effectively. However, neither
counteracts hypertonus to the extent desired.

The best propulsive stimulants are solution of posterior
pituitary, prostigmine, and ergotamine. Solution of pos-
terior pituitary acts in two minutes, prostigmine in
twenty minutes, ergotamine acts only to potentiate the
prostigmine. A combination of the three causes an
abrupt action which persists for six to eight hours.

Solution posterior pituitary 1% units

Prostigmine 0.25 mg.

Ergotamine tartrate 0.25 mg.

The great majority of these patients with unstable
colon have a hypertonic bowel — a bowel in which there
is increased nonpropulsive activity. A few have a hypo-
tonic bowel and complain of constipation without much
other distress. Senility, organic disease of the central
nervous system, and obesity are the most common fac-
tors underlying the hypotonic bowel. Vitamin B defi-
ciency and lack of calcium or potassium are occasional
factors.

Patients with hypertonic colon need our sympathetic
attention. They are not helpless psychopaths or invet-
erate neurotics in most cases. To verify this belief I
looked over the records of a hundred such patients who
have been under my care in the past year. Of this group
only 20 per cent had a definite formal psychoneurosis.
Another 20 per cent had a reactive depression (simple
situational reaction) to some difficult life situation. This
finding compares favorably with those of others. An-
other 40 per cent were afflicted with what one might call
faulty ways of living. In this group we have, among
others, the hurry-worry wart; the overly ambitious, emo-
tionally immature; those lacking in vigor who try to do
too much; the immoderate smoker, drinker, and eater;
and the perfectionistic fussbudget.

These people can be helped. They are not helped by
a brush-off. Surgery is not the way. In the group sur-
veyed I found that 42 per cent had had an appendec-
tomy, and of this group 68 per cent had the operation
for ' "chronic” appendicitis. Now, chronic appendicitis

is a rare disease; most pathologists say it does not exist.
Most gastroenterologists rarely feel justified in making
this diagnosis. Were these patients helped by surgery?
Each one was given a chance to answer. It happened
that all but one operated for chronic appendicitis claimed
he was made worse or was no better following the opera-
tion. Twenty-three per cent claimed postoperative ad-
hesions. Several of these patients had had multiple
abdominal operations, including operations for the release
of adhesions. Still they were no better.

No, I am afraid the surgical approach to this problem
leaves much to be desired. This is not to say that opera-
tion should not be done where the history definitely
indicates chronically recurring acute appendicitis. Cer-
tainly we should consider very deeply before operating
with the unsatisfactory diagnosis of "chronic” appen-
dicitis.

I have found it helpful to consider treatment under
four headings when advising these patients.

1. General Measures. This is the most important
part. It includes reassurance through careful history,
physical, and requisite laboratory examination. Our find-
ings must be adequately explained to the patient. A
brief explanation of how pain can develop without or-
ganic disease is imperative. Their "motor” is out of
tune. They may be racing their motor. They have to
watch their personal speedometer every hour of the day
and not exceed the limit. Faulty habits and attitudes
should be discussed if possible. Eliminate the hurry-
worry habit. Regularity of living, eating, sleeping, and
working, with time off for a little recreation, is stressed.
A 20-minute rest period after lunch and again after the
evening meal should be arranged if possible. Tell the
patient it took time to get sick and it will take time
to get well. Coffee, tea, and alcohol are permitted only
in moderation.

2. Diet. I recommend a bland diet. It is important
to emphasize the essentials of nutrition so that deficiency
disease will not develop.

3. Bowels. Desensitization against the fear of the
evils of constipation, emphasizing proper habit forma-
tion, is essential. If a little added help is needed I prefer
mineral oil at bedtime, or 1 to 2 glasses of normal saline
before breakfast each morning. Later a bulk former
may be needed as the bowel relaxes.

4. Medication. For the first month trasentin or bella-
donna and/or mild sedation may be necessary. Since our
antispasmodics are not so potent as we should like, re-
member not to send a boy to do a man’s job. In atonic
constipation I have used prostigmine bromide gr. % to
% at breakfast. In a few cases I have used ergotamine
tartrate gr. 1/60 to potentiate the prostigmine effect.

North Dakota State Medical Assn. South

Dr. James F. Hanna, Pres. Dr.

Dr. A. E. Spear, Pres. -Elect Dr.

Dr. L. W. Larson, Secy. Dr.

Dr. W. W. Wood, Ereas. Dr.

North Dakota Society of South

Obstetrics and Gynecology Dr.

Dr. E. H. Boerth, Pres. Dr.

Dr. Paul Freise, Vice Pres. Dr.

Dr. G. Wilson Hunter, Secy.-Treas.

Sioux

Minneapolis Academy of Medicine Dr.

Dr. Ernest R. Anderson, Pres. Dr.

Dr. Jay C. Davis, Vice Pres. Dr.

Dr. Cyrus O. Hansen, Secy. Dr.

Dr. Thomas J. Kinsella, Treas.

Dr J . O. Arnson
Dr. D. S. Baughman
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. A. R. Foss

Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. 1 . Mabee
Dr. J. C. McKinley

ADVISORY COUNCIL

Dakota State Medical Assn.
William Duncan, Pres.

F. W. Howe, Pres.-Elect
H. R. Brown, Vice Pres.
Roland G. Mayer, Secy.-T reas.

Dakota Public Health Assn.

J. M. Butler, Pres.

C. E. Sherwood, Vice Pres.
Gilbert Cottam, Secy.-T reas.

Valley Medical Assn.

D. S. Baughman, Pres.

Will Donahoe, Vice Pres.

R. H. McBride, Secy.

Frank Winkler, Treas.

Montana State Medical Assn.

Dr. S. A. Cooney, Pres.

Dr. M. A. Shillington, Pres.-Elect
Dr. R. F. Peterson, Secy.-Treas.

Northwestern Pediatric Society
Dr. G. B. Logan, Pres.

Dr. Geo. Kimmel, Vice Pres.

Dr. Northrop Beach, Secy.-T reas.

Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.

Dr. R. C. Webb, Secy.-Treas.

American Student Health Assn.

Dr. Ralph I. Canuteson, Pres.

Dr. Glenadine Snow, Vice Pres.

Dr. G. T. Blydenburgh, Secy.-Treas.

BOARD OF EDITORS

Dr. J. A. Myers, Chairman

Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C. H. Nelson
Dr. N. J . Nessa
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. C. E. Sherwood
Dr. M. A. Shillington

Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. C. A. Stewart
Dr. S. E. Sweitzer

Dr. W. H. Thompson
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin,
Secretary

LANCET PUBLISHING CO., Publishers, 84 South Tenth Street, Minneapolis 2, Minnesota

Minneapolis, Minnesota, February, 1946

PHYSICIANS TOO MANY OR TOO FEW

Not long ago — not so very long ago at least — this
ever complaining world contended that there was an
overabundance of physicians, and it was thought urgently
necessary to do something about it.

Faculty members, influenced by statistics, found the
most natural remedy in such a dilemma to be that of
raising the curriculum standard — a laudable thing to do
under the circumstances. But the motive did not long
remain in concealment. When this procedure failed to
accomplish the purpose of reducing the number of med-
ical students, someone in alarm suggested the desirability
of reducing the number of newly graduated physicians
who might be licensed to practice each year. However,
the cruelty of a system that encouraged a student to
toil for years to qualify for a profession, only to be
denied its practice on purely numerical grounds, became
evident. Much better, then, that a faculty member,
under the guise of a vocational guidance adviser, should

change the student’s course in early years. How much
of this was done we cannot say, but everyone knows that
a cataclysm supervened in this lofty program, and fate
ordered an about-face to provide medical personnel for
a great war. In turn, acceleration became the order of
the day.

And so we have the rhythmic pulsations that are ines-
capable in every progressive movement, and now accord-
ing to natural law we should look for deceleration. But
we shall see. Political philanthropy sees an opportunity
at this phase of the curve to continue its ascent to the
point where there shall be a doctor at every crossroad.
It seems a little incongruous that the government should
be expected to furnish every musher in the wilds of
Alaska with a physician at hailing distance and not
require a grocer to locate at a like proximity to his igloo.
Heaven knows man doth not live by medicine alone;
food is an even more necessary commodity.

A. E. H.

The Journal Lancet

THE NATION’S BIRTH AND MATERNAL
RECORD IMPROVES

Both babies and mothers now have a better chance of
survival, according to findings of a recent study made
by the U. S. Children’s Bureau. The record for the
decade 1933 to 1943 — the first period for which com-
parative statistics making such a study possible were
available — shows that the birth rate rose 30 per cent
from its all-time low in 1933, the number of live births
rose from two million to almost three million, and the
infant mortality rate was reduced almost one third and
the maternal mortality rate more than one half.

The major credit for this remarkable record, accord-
ing to the Children’s Bureau, belongs to the doctors, for
the work they have done in the care of women during
pregnancy and the improved care they are able to give
the mothers at childbirth and after delivery and to the
child in the dangerous early days and months of life.
Improvements in the economic status of many families,
allowing a better diet during pregnancy and enabling
more women to have hospital care during childbirth, and
improvements in hospital care are also important factors.

For the states representing the Journal Lancet re-
gion the comparative infant mortality rates per thou-

sand live births are as

follows:

1943

1933

Per Cent
Change

Minnesota

30.9

47.6

—35.1

Montana

38.7

51.5

—24.9

North Dakota

34.9

60.0

—41.8

South Dakota

35.7

54.8

—34.9

The maternal mortality

rates, per

10,000

live birth;

as follows:

1943

1933

Per Cent
Change

Minnesota

14.4

43.6

—67.0

Montana

17.5

57.0

—69.3

North Dakota

29.1

49.3

—41.0

South Dakota

15.6

48.2

—67.6

That the record is still not what it should be or could
be is evident. The Children’s Bureau points out that
"if the care we know so well how to give were available
to all groups of the population in all parts of the coun-
try ... we could cut still further the present tragic loss
of life.” To save the lives of more mothers and babies
we need more physicians, public health and hospital
nurses, and more hospitals and health centers.

MEDICINE AND CHANGE

To improve national health doctors and the public
must work together. Unless the public back up and
carry forward what doctors ask them to do, medical
progress will be slow.

Medical care grows better through two well-recognized
channels: through the channel of improving education
and through the channel of research. To keep these
channels wide and deep in a changing world is one of
the problems facing medicine today. — Reginald Fitz,
M.D., in The March of Medicine, New York Academy
of Medicine Lectures to the Laity, 1944.

ANNOUNCEMENTS

The Washington Institute of Medicine announces
publication of the Quarterly Review of Pediatrics, the
first issue to appear in February. The new review, de-
voted to abstracts from journals in this country and
abroad, has an editorial board of fifteen, with Dr. Irving
J. Wolman of Philadelphia as editor-in-chief. Two pedia-
tricians from the Central Northwest, Dr. Henry F.
Helmholz of the Mayo Clinic and Dr. Irvine Mc-
Quarrie of the University of Minnesota Medical School,
are members of the editorial board.

National Gastroenterological Association
1946 Award Contest

The National Gastroenterological Association an-
nounces the establishment of an annual cash prize award
of $100 and a certificate of merit for the best unpub-
lished contribution on gastroenterology or allied subjects.
Certificates will also be awarded those physicians whose
contributions are deemed worthy. Contestants residing
in the United States must be members of the American
Medical Association and those residing in foreign coun-
tries must be members of a similar organization in their
own country. The winning contribution will be selected
by a board of impartial judges, and the award will be
made at the annual convention banquet of the Associa-
tion, to be held at the Hotel Pennsylvania, New York
City, June 20, 1946.

Entries, to be limited to 5000 words, in English, type-
written and submitted in five copies with an entry letter,
must be received by May 1, 1946. They should be
addressed to the National Gastroenterological Associa-
tion, 1819 Broadway, New York, N. Y.

Sectional Meetings, American College
of Surgeons

The American College of Surgeons announces re-
sumption of its sectional meetings, which were replaced
by one-day sessions during the war. Ten two-day meet-
ings have been announced, as follows. Minneapolis, Ra-
disson Hotel, January 28-29; St. Louis, Hotel Jefferson,
January 31-February 1; Birmingham, Tutwiler Hotel,
February 8-9; Pittsburgh, William Penn Hotel, March
11-12; Boston, Statler Hotel, March 18-19; Montreal,
Mt. Royal Hotel, March 22-23; Detroit, Statler Hotel,
March 26-27; Salt Lake City, Utah Hotel, April 8—9 ;
Portland, Oregon, Multnomah Hotel, April 12-13; Los
Angeles, Biltmore Hotel, April 17-18.

The medical profession at large, medical students, and
hospital executives are invited to join with the Fellows
of the College in these meetings.

Among the subjects scheduled for discussion at meet-
ings for the medical profession are: treatment of infec-
tion by chemotherapy and the antibiotics; injuries to the
bile ducts; preoperative and postoperative supportive
treatment; treatment of open wounds; treatment of osteo-
myelitis; management of advanced cancer; care of the
veteran; and the reconversion period in the practice of
medicine. The hospital conferences will be devoted to
discussion of high standards for postwar hospitals, ap-
proached from the point of view of administration, pro-
fessional services, and care of different types of patients.

February, 1946

. . . IDEET OUR COflTRIBUIORS . . .

Dr. Owen Harding Wangensteen, Chief of the Depart-
ment of Surgery of the University of Minnesota Medical
School and Surgeon-in-Chief, University of Minnesota Hospi-
tals, had his medical training and internship at Minnesota, and
was then resident in surgery at the Mayo Clinic (1925) and
assistant in the Surgical Clinic of Professor F. de Quervain in
Berne, Switzerland (1927-28). A Diplomate of the American
Board of Surgeons and a Fellow of the American College of
Surgeons, he is a member of many professional societies, includ-
ing the American Society of Experimental Pathology, the Ameri-
can Surgery Association, the Society of Experimental Biology
and Medicine, and the Societe International de Chirurgie.

Dr. Wangensteen received the John Scott Award and medal
in 1941. Author of The Therapeutic Problem in Bowel Ob-
structions (1937), he is known for a suction syphonage treat-
ment of acute intestinal obstruction. "Wangensteen bottles"
are featured in "Sometimes You Break Even,” by Victor Ull-
man, a story appearing in the February 1946 Atlantic Monthly.

Dr. Ferdinand Ripley Schemm of the Great Falls (Mon-
tana) Clinic is a graduate of the University of Michigan Med-
ical School, with the degrees of B.S. (Med.) and M.D., and
had his postgraduate work there as well. Following some years
as instructor in Internal Medicine at the University Hospital,
Ann Arbor, he went to Great Falls, where he has practised
since 1933. He is a Diplomate of the American Board of In-
ternal Medicine (1937), a Fellow of the American College of
Physicians, and a member of several professional societies.

Dr. Dalton M. Welty, who has been an internist with the
U. S. Army on detached duty with the Veterans Administra-
tion at Hot Springs, South Dakota, for three years, is a grad-
uate of the Johns Hopkins School of Medicine (1939), with
postgraduate work at Johns Hopkins Hospital, Baltimore, and
Henry Ford Hospital, Detroit. He is a member of the Black
Hills District Medical Society.

Book JlouUws

Facial Prosthesis, By Arthur H. Bulbulian, M S., D.D.S.,

Director, Museum of Hygiene and Medicine, The Mayo

Foundation. Philadelphia: W. B. Saunders Co., 1945. Pp.

241, 202 illustrations. $5.00.

This excellent handbook on facial restoration fills a long-
standing need. World War I stimulated interest in prosthetic
reconstruction of missing parts, and the experience gained dur-
ing the conflict has since proved its value in correcting deformi-
ties due to malignant diseases of the face and jaw. Never has
there been more interest in the subject than at present. Yet,
although prosthetic restoration of the extremities is well stand-
ardized in orthopedics, the highly specialized subject of facial
prosthesis is nearly unknown to surgery. The literature is
almost entirely confined to dental periodicals and books, and
even in the dental profession few are qualified to solve the
problems of facial and maxillary repair.

Although these problems are clearly the province of the sur-
geon, many factors may contraindicate surgical treatment. In
such cases the missing parts may be artificially restored, either
temporarily or permanently. For the person interested in this
subject, the author provides a concise introduction to prosthetic
theory and technic. He limits himself to artificial restoration
of the face, particularly the ear, nose, and orbit, omitting the
maxillary restorations which are frequently involved. In stress-
ing latex he has somewhat slighted the importance of acrylics
and other suitable materials.

The subject matter in the fourteen chapters is well classified,
and the diagrams and illustrations are carefully planned to sup-
plement descriptions of procedures. This small volume satisfac-
torily demonstrates the function of prosthesis in repairing de-
formities of the face. — C. W. Waldron.

The Arthropathies: A Handbook of Roentgen Diagnosis,

by Alfred A. de Lorimier, Colonel, Medical Corps, U. S.
Army. Chicago: The Year Book Publishers, 1943. Pp. 319,
illustrated.

The Year Book Publishers have put out a series of books on
X-ray diagnosis, of which this is one. The material is divided
into two parts: peripheral joints and joints of the spine. Each
part considers developmental anomalies, diseases associated with
mechanical stress, the arthritides, neoplasms, and, finally, mis-
cellaneous disorders. Illustrations are profuse and carefully
marked with arrows and letters demonstrating the pathological
processes. Within the limits imposed by the Year Book format,
not too well suited to a pictorial subject, de Lorimier has pro-
duced an excellent treatise on joint disorders.

Men Without Guns. Text by De Witt Mackenzie; descrip-
tive captions by Major Clarence Worden; foreword by
Major General Norman T. Kirk. 177 paintings and
sketches by contemporary artists, with 118 plates in full
color. Philadelphia: The Blakiston Company, 1945. 152

pages. $5.00.

Here is the story of the part played in the war by the in-
defatigable doctors, nurses, and corpsmen of the Army Med-
ical Department, told most vividly in the plates that make up
the major part of the book.

The Abbott Collection of Paintings, now the property of the
United States Government, from which the illustrations are
taken, is the result of the cooperative thought and work of a
considerable group of men, including Lt. Col. Howard F. Baer,
whose idea it was; the Abbott Laboratories, who sponsored the
project; the War Department; the Associated American Artists;
and, by no means least, the twelve artists, some of whom im-
periled their lives and suffered many hardships in gathering the
material for their work.

These twelve artists are: Howard Baer (not related to Lt.

Col. Baer), who was assigned to the Burma-China-India front
and made by far the largest number of paintings and sketches,
namely, 55; Robert Benney, Western Pacific, 31; Peter Blume,
Halloran General Hospital, 1 ; Franklin Boggs, Southwest Pa-
cific, 18; Francis Criss, Army Medical Center, Washington, 7;
John Steuart Curry, Army Medical Department training school,
Camp Barkeley, Texas, 12; Ernest Fiene, plants of medical in-
dustry on the home front, 10; Marion Greenwood, England
General Hospital, Atlantic City, 24; Joseph Hirsch, Medi-
terranean Theatre, 22; Fred Shane, Army Medical Department
training school at Carlisle Barracks, Pennsylvania, 14; Lawrence
Beall Smith, European Theatre, 18; Manual Tolegian, Army
Nurse Corps training school, Camp White, Oregon, 10.

Memorable stories of the artists’ experiences while getting
their material are included in the text. The descriptive cap-
tions are vivid and telling.

Doctors who took part in the magnificent work of the Army
Medical Department will want to own this book. So will many
others for whom, to use the Aristotelian phrase, the pity and
terror of the tragedy depicted in these pictures will serve to
reinforce the determination that it shall not happen again.

Prescribing Occupational Therapy, by William Rush
Dunton, Jr., M.D. 2d ed., revised. Springfield, Illinois:
Charles C Thomas, 1945. Pp. 156. $2.50.

This book, reprinted in response to many requests, has been
completely revised, with a chapter on rehabilitation and up-to-
date references added.

Dr. Dunton, a pioneer who has contributed much to the
wholesome later development of occupational therapy, is a keen
observer. As he states in the preface to the first edition, occu-
pational therapy has not been included in the curriculum of the
medical school until recently, and few medical teachers have
given the subject more than passing mention. The physician
who senses that occupational therapy could be of help to pa-
tients met in his private practice therefore has little information
upon which to proceed. One objective of Dr. Dunton’s book
is to give the busy physician this needed insight. To do so he

The Journal Lancet

has drawn on the entire related occupational therapy literature,
much of which is accessible largely through the author’s efforts
as editor of the Maryland Psychiatric Journal and the journal
of the American Occupational Therapy Association, Occupa-
tional Therapy and Rehabilitation. Dr. Dunton’s rich personal
experience in the field is felt throughout the book.

While the author has aimed at brevity, the scope of the
book is broad. Part 1 presents chapters on significance, prescrip-
tion, and fatigue. In accepting the definition that occupational
therapy is "any activity, mental or physical, definitely prescribed
and guided for the distinct purpose of contributing to, and
hastening of recovery,” the field of activity is recognized to be
as broad as the needs of sick humanity. The over-all aim of
occupational therapy in aiding recovery is clarified by presenting
specific objectives indicated by the form of illness. The chapter
on prescription is well summed up in the following items to be
considered before writing a prescription: first, the object to be
obtained; second, the type of occupation; third, the contraindi-
cations which may influence choice of occupation; fourth, a
necessary precaution, "the better understanding of the patient
given the therapist, the more intelligent the application of
treatment.”

Part 2 presents the special application of the general prin-
ciples of occupational therapy to mental disorders, general medi-
cine, surgical cases, orthopedic cases, cardiac cases, tuberculosis
cases, children, and bed patients.

In the last chapter rehabilitation, or "the return of the phys-
ical or mental invalid to his former usefulness as a member of
society,” is briefly considered. Occupational therapy, having
aided and hastened recovery, can do much to prepare the indi-
vidual for and assist him in making a satisfactory return to
normal.

The therapist has available interesting crafts and other tech-
niques which may be so adapted to meet special needs that sat-
isfactory performance can be guaranteed. The fear of being
different can be best eliminated by thus transferring the focus
of attention to actual performance. When the psychological
readjustment has become an accomplished fact, rehabilitation
can be undertaken with the assurance of the patient’s complete
cooperation.

The patient's cooperation and reaction to a treatment pro-
gram can be largely conditioned by the degree of insight of
those interested in him. This book, therefore, should be most
helpful not only to the physician, occupational therapist, and
nurse, but also to the friends and relatives of patients.

Structure and Function of the Human Body, by Ralph N.
Baillif, Ph.D., and Donald L. Kimmel, Ph D. Philadel-
phia: J. B. Lippincott Company, 1945. Pp. 328, illustrated,
#3.00.

A basic biological principle, the relationship of structure and
function, is recognized in this new textbook for beginning
science students by Professors Baillif and Kimmel. The authors
have attempted to fill what they believe to be a need for an
efficiently concise description of the anatomy and physiology of
the human body. Students will welcome the shortness of this
book (328 pages), as well as its careful introduction to scien-
tific terms and its numerous clear, useful diagrams.

The authors begin with a consideration of the building units
of the body: protoplasm, cell and tissue structure, membrane
function, and the organ systems of the body. The structure-
function relationship is emphasized in this introductory survey.
The bulk of the book is devoted to a more detailed description
of the systems, which are divided into related groups. In spite
of the authors’ expressed desire to eliminate the less essential
facts, they have included a great many anatomical details which
seem unnecessary for the beginning student. As a result, there
is decidedly more emphasis upon structure than upon function.

In Grandfather’s time the doctor's most potent weapons were
his personality and his art. He knew his patients intimately,
he had time to reflect upon the mysteries of man’s psychic
make-up, and he was a father confessor as well as a healer. —
(Kattwinkel, in New England J. Med.)

HuMloyt?

Dr. John Francis Curtin, 57, of Minneapolis, died
December 25, 1945, after a long illness. He was presi-
dent of the medical staff of Abbott Hospital and was
also on the medical staff of Asbury, Northwestern, and
St. Mary’s hospitals.

Dr. Edwin L. Gardner, 59, of Minneapolis, special-
ist in internal medicine and professor at the University
of Minnesota for 30 years, died January 30, 1946.

Dr. William L. Gordon, 72, of Washburn, North
Dakota, died December 9, 1945, in Bismarck. Dr. Gor-
don, an obstetrician, was born and educated in Kentucky.
He had practised in North Dakota since 1901 and for
32 years in Washburn.

Dr. Paul Lincoln Greene, 60, physician and sur-
geon of Livingston, Montana, since 1912, died at Mis-
soula January 5, 1946, after a long illness. Dr. Greene
had served in the Army Medical Corps in both world
wars. At the time of his death he was chief surgeon for
the Northern Pacific Railway in Livingston.

Dr. Donald Welsh Gudakunst, 51, medical di-
rector of the National Foundation for Infantile Paraly-
sis, died of a heart attack in Chicago on January 20,
1946. Dr. Gudakunst, who had his B.S. and M.D. from
the University of Michigan and also spent his interne-
ship there, had a long record in medicine and public
health and was one of the country’s leading authorities
on poliomyelitis. His home was in Westport, Con-
necticut.

Dr. Ernest Wesley Rimer, 63, practising physician
and surgeon of Breckenndge, Minnesota, for more than
30 years, died December 22, 1945, after a brief illness.

Dr. Arthur William Shaleen, 68, of Hallock,
Minnesota, died January 8, 1946.

Dr. Frank Dale Smith, 64, of Rochester, Minne-
sota, died December 5, 1945. He had practised at Kas-
son for 22 years before going to Rochester in 1937.

Dr. Gustave Windesheim, 91, dean of physicians of
Kenosha, Wisconsin, died January 19, 1946. Dr. Win-
desheim, born in Alsace Lorraine in 1854, practised in
Chicago for many years before going to Kenosha. He
retired in 1938.

Army Psychiatric Experiences of Value to
Civilian Institutions

Industrial, educational, and criminal institutions and
society in general can derive benefit from the psychiatric
experience of the Army Medical Department in World
War II, according to Brigadier General William C.
Menninger. Two major innovations in Army treatment
of neuropsychiatric cases are psychotherapy under seda-
tion and group psychotherapy. Through psychotherapy
under sedation the patient is given "free and adequate
drainage” for his emotional tension, an important factor
in recovery. In group psychotherapy a group of patients
with similar problems meet an hour a day for ten to
thirty discussions, under the leadership of a psychiatrist.

February, 1946

Views Items

A plan to expand the staff and improve the medical
care at the Minneapolis Veterans Hospital, making it
one of the leading veterans’ medical centers in the coun-
try, has been announced by Dr. Harold S. Diehl, dean
of medical sciences at the University of Minnesota, Carl
D. Hibbard, manager of the Minneapolis Veterans Ad-
ministration, and Dr. Harry E. Bank, chief medical
officer of the hospital.

The plan provides for placing the hospital on Uni-
versity Medical School standards through supervision of
all appointments of physicians by the dean; introduction
of specialists drawn from all parts of the country under
supervision of a Dean’s Committee; setting up a fellow-
ship system under which 68 doctors, graduates of the
University Medical School, will work in the hospital on
a full-time basis while obtaining specialists’ ratings; and
constituting ability, rather than civil service status, the
primary basis for appointment of physicians, with vet-
erans given voluntary preference wherever possible.

The program will add 35 men with rank of senior
consultant, 43 consultants, and 68 resident physicians
or fellows.

Dr. James Blake, pioneer physician in the Lake Min-
netonka region, is still in active practice at 73, after 43
years of service. Dr. Blake estimates that he delivered
125 to 150 babies annually during his first 25 years of
practice. In World War I he examined drafted men
at 10 cents each, and in World War II he examined
many more free of charge. He was a "horse and buggy
doctor” till 1910, and since then has worn out some
cwenty-five cars. Dr. Blake has three doctor sons, two
of whom, Capt. Allen J. Blake and Capt. Paul S. Blake,
are still in service. Dr. James A. Blake, recently released
from service, is in practice with him.

Dr. W. C. Ehmke, physician at Willow River, Minne-
sota, for forty years, was honored on January 20, his
65th birthday, by a surprise gathering of hundreds of
friends and neighbors of northern Pine County.

Dr. Edward B. Kinports, former major in the Army
Medical Corps, reviewed his experiences as a surgeon at
clearing stations and hospitals in the Pacific Theater at
a luncheon meeting January 21 at International Falls,
Minnesota, and described some of the improvements in
medical technics that saved the lives of thousands of
wounded American soldiers.

Dr. L. H. Clerf, Philadelphia, Dr. A. W. Proetz,
St. Louis, and Dr. F. T. Hill, Waterville, Maine, were
the principal speakers at the biennial continuation course
for ear, nose, and throat specialists at the University of
Minnesota in January. Specialists attending the course
also attended a one-day meeting of the middle section
of their professional society at the Curtis Hotel, with
Dr. A. C. Furstenberg of Ann Arbor presiding.

The Minneapolis Academy of Medicine paid tribute
in January at its annual senior meeting to seven hon-

orary members: Dr. E. T. Bell, Dr. Harold S. Diehl,
Dr. Benjamin J. Clawson, Dr. George D. Head, Dr.
Henry L. Ulrich, and Dr. Richard E. Scammon, all of
the University of Minnesota, and Dr. Adolph M. Han-
son of Faribault. Forty senior members of the academy
were also honored.

According to Dr. E. L. Tuohy of Duluth, the dis-
advantageous health and medical conditions of rural
America recently outlined by the U. S. Department of
Agriculture do not obtain in rural Minnesota. Speaking
especially of conditions in St. Louis County, Dr. Tuohy
pointed out that excellent roads and transportation per-
mit easy access to almost every point in • the county’s
rural area from nearby towns; that doctors are attracted
even to small towns in the county, especially on the iron
range, where adequate support and facilities are assured;
that medical examinations of all school children are re-
quired; and that nursing service is provided for schools
and rural communities.

As president of the Minnesota State Medical Society,
Dr. Tuohy announced that Minnesota is considering a
medical plan for veterans similar to that now in effect
in Michigan, which, through a cooperative arrangement
with the Veterans Administration, provides that war
veterans with service-connected disabilities may receive
treatment at government expense from doctors of their
choice in their home communities.

Dr. E. S. Mariette, superintendent of Glen Lake
Sanatorium in Minneapolis since its opening, was hon-
ored by the staff in January in a celebration of the
thirtieth anniversary of the sanatorium.

Dr. Ernest R. Anderson has been re-elected president
of Asbury Hospital medical staff in Minneapolis for
1946.

Dr. G. W. Clifford and Dr. E. R. Sather, both of
Alexandria, Minnesota, have been elected respectively
president for 1946 and 1947 of the Park Region Med-
ical Society, comprising physicians of Douglas, Grant,
and Otter Tail counties.

Dr. Jean Verbrugge of Antwerp, Belgium, chairman
of the Belgian Society of Orthopedic Surgery, said in
Minneapolis recently that observations he made on a
tour throughout the United States prove that this coun-
try leads the world in orthopedic surgery. He attributes
this leadership to the American organization of post-
graduate teaching, to which many surgeons devote them-
selves beyond the sphere of their own practices.

The annual George Chase Christian lecture will be
given at the University of Minnesota by Dr. Leonell C.
Strong of Yale University School of Medicine on
Thursday, February 7, at 8 p.m., in the auditorium of
the Museum of Natural History. His subject will be
"Mice, Men, and Malignancy.” Dr. Strong will speak
also at 4:30 p.m. on February 6 in 214 Millard Hall on
"Experimental Gastric Carcinoma in Mice.”

The Journal Lancet

Dr. Eugene Hildebrand, formerly of Northwestern
University Medical School, is now pathologist and
director of laboratories of the Great Falls (Montana)
Clinic.

Dr. James MacGregor of the North Montana Clinic,
Great Falls, has been re-elected vice president of the
United States chapter of the International College of
Surgeons.

Dr. James E. Garvey has resigned as city physician of
Butte, Montana, on the return of Dr. Neil O’Keefe to
that post from service overseas.

Dr. Richard R. Brady, formerly of Livingston, Mon-
tana, has been appointed executive officer of Dibble
General Hospital at Menlo Park, California.

The Hawkins-Lindstrom Clinic was opened in Helena,
Montana, in December 1945, with Dr. Thomas L.
Hawkins, Dr. Everett H. Lindstrom, and Dr. O. M.
Moore as members of the staff.

The Sheyenne Valley Medical Society met January 9
at Valley City, North Dakota. The newly elected offi-
cers are Dr. Paul T. Cook, President; Dr. J. P. Merrett,
Vice President; Dr. C. J. Meredith, Secretary and
Treasurer. Dr. A. C. Macdonald, Dr. J. P. Merrett,
and Dr. L. Almklov were elected to the Board of
Censors, Dr. Paul T. Cook as delegate and Dr. A. C.
Macdonald as alternate. Dr. W. H. Gilsdorf and Dr.
H. Christianson are new members of the society.

Surgeon General Thomas Parran has announced that
appointments to fill vacancies in the Reserve Corps of
the U. S. Public Health Service are being made and
that examinations for appointments to the Regular Corps
will be held in April and May. Physicians, dentists, and
nurses are needed at once for duty in hospitals, in the
tuberculosis and venereal disease control programs, and
other activities.

National Negro Health Week is announced for
March 31 to April 7, 1946, by the U. S. Public Health
Service. The 1946 week represents the 3 2d observance
of this occasion.

A nation-wide program to expand and accelerate its
fight against crippling diseases affecting children will be
set into action at once by the Shriners of North Amer-
ica. The five-point program comprises the granting of
scholarships in orthopedic surgery to outstanding quali-
fied medical students, with three scholarships of $2,500
each to be made in 1946 for training in three universi-
ties, soon to be named; an annual appropriation of
$3,750 for scholarships in orthopedic nursing; the estab-
lishment of a research project to investigate the sources,
methods of treatment, and prevention of crippling dis-
eases attacking children; the expansion of present facili-
ties and equipment of the fifteen Shriners’ hospitals now
in operation (one of which is located in the Twin Cities),
and the establishment of new hospitals; and the estab-
lishment of convalescent homes in connection with all
Shriners’ hospitals. Dr. J. Albert Key, president of the
American Orthopedic Association, bespeaks the associa-
tion’s endorsement of the expanded program.

The 1946 Albert and Mary Lasker Foundation awards
for the most significant contribution to research in hu-
man fertility and for meritorious public health service
have been presented to Dr. Robert Latou Dickinson and
Dr. Irl Cephas Riggin. Dr. Dickinson, distinguished
gynecologist and obstetrician, notes among the improved
procedures he has sponsored one in "the only operation
done on every human being — amputation of the umbili-
cal cord at birth,” application of the methods of modern
surgery, in that, to avoid sloughing of tied stumps, he
cut, then ligated and sutured with a single strand, secur-
ing primary union. Dr. Riggin is the progressive State
Health Commissioner of Virginia, seventh state to make
planned parenthood services available as part of the
state’s public health program of maternal care.

Dr. Albert L. Raymond, formerly director of research,
has been made vice president in charge of research of

G. D. Searle & Co., Chicago.

The Office of the Surgeon General announces that
fourteen more Army General Hospitals will be closed by
March 31. Out of a wartime peak of 65 General Hos-
pitals operated by the Army Medical Department, 20
have already been closed, and of the peak of 13 Army
Service Forces Convalescent Hospitals, three have been
closed.

The Surgeon General calls attention also to the pro-
visions of Public Law 281, providing for the procure-
ment of additional officers for the Army Medical De-
partment, and the postwar plans of the department,
providing for opportunities for professional advancement.
Every effort will be made to provide professional, rather
than administrative, assignments, for officers who desire
them. Applications for appointments in the Medical
Corps may be submitted to reach the Adjutant Gen-
eral’s Office, Washington 25, D. C., not later than
March 1, 1946. Application must be made on the appro-
priate form, available from any Army unit or installa-
tion headquarters.

The Mayo Professorship in Public Health, recently
created, is the first permanently endowed professorship
of the University of Minnesota. Appointment to the
new professorship, endowed by the Mayo Properties
Association, is expected to be made before July 1. Dr.
Harold S. Diehl, Dean of Medical Sciences, says of the
new chair: "For the Medical School it provides an ulti-
mate and effective bond with the graduate work and
public health interests of the Mayo Foundation. It rep-
resents also a permanent tribute to and reminder of the
broad and humanitarian interests of the Doctors Mayo.”

Dr. J. R. Ohlmacher has been named pathologist of
St. Patrick’s Hospital, Missoula, following his return
from five years with the Army Medical Corps. Newly
elected officers of the hospital staff are Dr. C. H. Fred-
erickson, preisdent; Dr. W. E. Harris, vice president;
Dr. Ohlmacher, secretary; and Dr. E. C. Murphy, Dr.

H. M. Blegen, and Dr. C. F. Honeycutt, members of
the executive board.

February, 1946

The Flathead County (Montana) Medical Society
has elected the following officers for 1946: Dr. L. G.
Griffis, president; Dr. Tom B. Moore, vice president;
Dr. R. L. Towne, treasurer; and Dr. H. D. Fduggins,
secretary.

The Yellowstone Valley (Montana) Medical Society
has elected the following officers: Dr. Fdarry O. Drew,
president; Dr. John C. Powers, president-elect for 1947;
Dr. Fdarold E. McIntyre, secretary; and Dr. John J.
Hammerel, treasurer.

The Silver Bow County (Montana) Medical Society
elected the following officers at its annual meeting held
in Butte in January: Dr. Peter T. Spurck, president;
Dr. D. A. Atkins, vice president; Dr. S. V. Wilking,
secretary; and Dr. C. R. Canty, treasurer.

The Montana Physicians’ Service has been organized
on a nonprofit basis to provide the people of Montana
with medical care on a budget basis, with Dr. M. A.
Shillington of Glendive as president. The service will
work in cooperation with the Montana Blue Cross hos-
pitalization organization. The service was set up with the
assistance of Dr. C. L. Cooley, president of the San
Francisco County Medical Society and board secretary
of the California Physicians’ Service. The new group
will cooperate with the California service in the veterans
medical care program.

Montana physicians and surgeons representing twenty
county medical societies met at Butte January 18-19 for
a special delegate meeting of the Montana State Med-
ical Association.

Dr. O. J. Hagen, still in active practice in Fargo and
Moorhead at the age of 73, after nearly forty years,
was honored at a testimonial dinner at the Moorhead
Country Club in January.

Dr. L. W. Larson, Bismarck, has been appointed to
the public health advisory board as successor to Dr.
John H. Moore, Grand Forks.

According to a national survey three North Dakota
Counties, namely, Billings, Oliver, and Slope, have no
resident physicians within their borders, and one of the
largest of the fifty other counties has only one physician.

North Dakota’s blood plasma program, described in
an article by Melvin E. Koons in the January Journal
Lancet, has been studied by Dr. Charles Hunter of the
Kansas State Board of Health and Dr. R. D. Dixon of
Topeka, Kansas, who will direct the organization of a
similar program in their home state.

Ten doctors were licensed to practice medicine in
North Dakota at Grand Forks on January 5. They are
John E. Ruud, Charles M. Graham, and Neal C. Per-
kins, all of Grand Forks; Clair L. Ingalls and H. Paul
Johnson, Minot; Russell O. Saxvik, Bismarck; Edward

J. Hagen and Alan K. Johnson, Williston; Margaret
Hatfield, Jamestown; and H. G. Cleary, Sharon.

Dr. Kenneth E. Fritzell, formerly of Minneapolis, is
now associated with the Grand Forks Clinic.

A survey of North Dakota hospitals and maternity
homes is being conducted by the hospital subcommittee
of the state health planning committee, preliminary to
applying for the state’s share in proposed federal hos-
pital construction funds.

Dr. A. L. Cameron of the Northwest Clinic, Minot,
announces that Dr. H. P. Johnson, ophthalmologist,
formerly of the Mayo Clinic, Dr. Clair L. Ingalls, sur-
geon, formerly with the Army Medical Corps, and Dr.
Arnold B. Coombs, ear, nose, and throat specialist, for-
merly of the University of Michigan Medical School
and the U. S. Navy, have joined the clinic staff.

Doctors beginning or resuming practice in North Da-
kota following military service include: Dr. Malcolm
McCannel, Dr. J. L. Devine, and Dr. V. J. Fischer,
Minot; Dr. Charles A. Arneson and Dr. Ralph Mon-
tague, Bismarck; Dr. A. R. Gilsdorf, Dickinson; Dr.
Earl M. Haugrud, and Dr. Arthur C. Burt, Fargo; and
Dr. Charles M. Graham, Grand Forks.

Dr. I. H. Mauss has left Rapid City, South Dakota,
where he was county and city health officer, for Mem-
phis, Tennessee, where he has been assigned to the U. S.
Marine Hospital.

The Watertown (South Dakota) District Medical
Society has elected the following officers for 1946: Dr.
Abner Willen, president; Dr. A. B. Scheib, vice presi-
dent; Dr. G. Robert Bartron, secretary-treasurer; Dr.
Stanley J. Walters, delegate, and Dr. R. H. Maxwell,
alternate, to state convention; and Dr. George H. Rich-
ards, censor.

The South Dakota Public Health Association has
elected the following officers for 1946: Dr. Clarence E.
Sherwood, Madison, president; Dr. H. Russell Brown,
Watertown, vice president; Dr. Gilbert Cottam, Pierre,
re-elected secretary-treasurer. Dr. F. T. Younker, Sisse-
ton, was named member of the board of trustees, suc-
ceeding the late Dr. E. M. Young.

The Seventh District Medical Society, meeting at
Sioux Falls, elected Dr. Rezin Reagan, president; Dr.
J. A. Nelson, vice president; Dr. C. J. McDonald, sec-
retary-treasurer; and Dr. L. G. Leraan, board of
directors.

Twenty-four South Dakota physicians, selected from
among those in general practice in each medical district
of the state, will attend a refresher course on cancer at
the University of Minnesota in the spring of 1946. All
expenses will be paid by the American Cancer Society.

The Journal Lancet

FOLLOW-UP NOTES TO "THE ULCER PROBLEM,”
BY DR. OWEN H. WANGENSTEEN, PAGES 31-49

The following notes, representing recent findings, were sent
by Dr. Wangensteen too late to be included in the text.

Cases 1—4, p. 38. More recent observations indicate that all
four patients continued well without any further suggestion of
recurrent hemorrhage.

Case 1, p. 39. Mr. F. K. died of ascites and recurrent hem-
orrhage in December 1945. At autopsy a complete thrombosis
of the portal vein was found. As will be indicated later, it is
to be noted that a 90 per cent resection will not protect con-
sistently against the histamine provoked ulcer in dogs in which
portal hypertension has been established.

Cases 2 and 4 (p. 40) continue well without recurrent hem-
orrhage.

Section D, p. 43. Recently evidence of a gastrojejunal ulcer
has occurred in a second patient, Mr. W. P., operated upon by
me three years previously for a gastrojejunal ulcer following a
gastrojejunostomy. Because the patient was obese only a 65
per cent gastric resection was done. Experience indicates that
in such obese hypersthenic patients at least a 75 per cent resec-
tion is mandatory. In other words, the cause of recurrent
stomal ulcer here was an inadequate gastric resection. The pa-
tient appears to be getting on satisfactorily with conservative
medical management.

AdveAtUete'

SPARKLING, EFFERVESCENT FORM OF
CALCIUM GLUCONATE

Because calcium generally must be administered over a pro-
longed period of time — throughout pregnancy and lactation,
during infancy and childhood, in convalescence, etc. — accept-
ability of the dosage form is an important factor.

In Calcium Gluconate Effervescent (Flint) the physician has
a means of supplying full therapeutic value in a sparkling,
pleasant-tasting form. When added to water, Calcium Glu-
conate Effervescent (Flint) forms an effervescent, palatable
drink which even the taste-conscious patient finds acceptable.

Each gram of Calcium Gluconate Effervescent (Flint) con-
tains calcium gluconate U.S.P. 0.5 Gm, citric acid 0.25 Gm.,
sodium bicarbonate 0.25 Gm. Council accepted.

Average dose: 1 to 1 Vi teaspoonfuls. Contains 48 to 52

per cent calcium gluconate.

WHITE LABORATORIES’ MOL-IRON

White Laboratories, Inc., has an important product for the
treatment of iron-deficiency anemias, White’s Mol-Iron. Sup-
plied in tablet form, White’s Mol-Iron is described as a spe-
cially processed, co-precipitated complex of molybdenum oxide
(3 mg.) and ferrous sulfate (195 mg.)

Based on available clinical evidence, it is stated that the use
of Mol-Iron effects approximately 100% greater therapeutic
utilization of iron, and 100% more rapid regeneration of hemo-
globin than does ferrous sulfate. In addition, it is said that
gastro intestinal reactions are notably absent, even among pa-
tients exhibiting such symptoms in response to other commonly
used iron preparations. Mol-Iron is available in bottles of 100
and 1000. It is promoted solely for prescription by the medical
profession and is currently available in most prescription phar-
macies.

NEWS FROM WINTHROP CHEMICAL

Pure synthetic Vitamin Da (calciferol) has been made avail-
able in this country by Winthrop Chemical Company, Inc.,
according to a recent announcement by Dr. Theodore G.
Klumpp, president.

Free from lumisterol, toxisterol, suprasterol and other by-

products of irradiation, the product is said never to vary in
antirachitic potency. It will be marketed by the special markets
division of Winthrop to the pharmaceutical industry, the evap-
orated milk industry and others. The crystalline form of cal-
ciferol will be available in ampules of 1, 5, and 10 grams, with
40 million U.S.P. units per gram and also a solution in corn oil.

NEW SCHERING REPRESENTATIVE IN
MINNESOTA

Schering Corporation, with plants in Bloomfield and Union,
New Jersey, manufacturers of endocrine and pharmaceutical
products for the medical profession, has appointed Earl L.
Heidick as professional service representative in Minnesota,
with headquarters at Minenapolis.

Mr. Heidick, a former employee of Schering Corporation, is
a graduate of the University of Miami with a major in the
field of chemistry. He was recently released from the U. S.
Army Air Forces, in which he attained the rank of Captain
and Squadron Commander. He has a record of forty missions
in the Pacific Theater.

WYETH’S CONESTRON

An oral product for the menopausal patient is the Conestron
tablet of natural conjugated estrogens to provide completely
effective oral therapy which method of administration has
already demonstrated its superiority over the time-consuming in-
jection therapy. Not only has it wide acceptance by the medical
profession but it bids fair to become the preferred therapy.

Highly potent, usually requiring only one tablet daily,
Conestron is essentially safe and assures the patient’s sense of
well-being with a minimum of side effects. This addition to
the Wyeth line of prescription items is packaged in two sizes —
bottles of 100 and 1,000, each containing 0.625 mg. Estrone
Sulfate.

PHYSICIAN-ARTISTS’ PRIZE CONTEST

The American Physicians Art Association, with the coopera-
tion of Mead Johnson & Company, is offering an important
series of War (Savings) Bonds as prizes to physicians in the
armed services and also physicians in civilian practice for their
best artistic works depicting the medical profession’s "skill and
courage and devotion beyond the call of duty.”

For full details, write to the Association’s Secretary, Dr. F.
H. Redewill, Flood Bldg., San Francisco, Calif., or Mead John-
son & Co., Evansville 21, Ind. Also pass this information on
to your physician-artist friends, both civilian and military.

NEW TABLETS FOR B-COMPLEX THERAPY

Hoffman-La Roche, Inc., of Nutley, N. J., this fall announced
to the medical profession the introduction of Berocca Com-
pound tablets. These exceptionally small, well-tolerated tablets
are particularly useful for the prevention and treatment of vita-
min B-complex deficiencies, for they supply generous amounts
of vitamins Bj, Ba, Bn, niacinamide and calcium pantothenate in
a form readily acceptable to the most fastidious patient. The
tiny, smooth tablets are so easy to swallow that even finicky
children will raise no objections to taking them. In spite of
their high potency and pharmaceutical elegance, Berocca Com-
pound tablets are so low in cost that they can be prescribed for
practically every patient without imposing an economic burden.
Berocca Compound tablets may be administered with complete
confidence in all disorders in which B-complex therapy is indi-
cated. Clinical samples and literature will be furnished upon
request.

BURROUGHS WELLCOME INTRODUCES
LUBAFAX SURGICAL LUBRICANT

Burroughs Wellcome & Company is introducing a new and
improved surgical lubricant under the brand name of Lubafax.
Lubafax is readily soluble in hot or cold water, will not injure
metal or rubber instruments, is nonirritating and bacteriostatic,
possesses excellent adhesive and cohesive properties, is trans-
parent and odorless, and will not stain instruments or clothing.
Lubafax is available in tubes of 2 oz. at $.25 and 5 oz. at $.35
(list prices) .

A Comparison of the Response of Gonorrhea to
Sulfathiazole and Penicillin

( Analysis of 144 cases)

I. H. Mauss, M.D.

Rapid City, South Dakota

THE purpose of this paper is to survey and com-
pare the results obtained in treating gonorrhea
with sulfathiazole and with penicillin in the rou-
tine operation of a venereal disease clinic.

The patients were treated in the Venereal Disease
Clinic of the Pennington County (South Dakota)
Health Department. Three patients sent to the U. S.
Public Health Service Medical Center, Hot Springs,
Arkansas, received penicillin treatment there before it
was available locally, but were kept under observation by
us after treatment. Most of those who received sulfa-
thiazole were patients at the Black Hills Rapid Treat-
ment Center,* * which was operated under the supervision
of the director of the Pennington County Health De-
partment.

Methods

LABORATORY PROCEDURE

1. The laboratory work was done at the Black Hills
Branch of the Division of Laboratories of the South
Dakota State Board of Health, in Rapid City. The
smear and culture technics employed were essentially
those described by Carpenter.1

OBTAINING THE SPECIMEN

Females. Specimens for smear and culture were ob-
tained from the cervix as described by Carpenter.1 Ur-
ethral specimens were not taken unless there was urethral

From the Pennington County (South Dakota) Health Depart-
ment. Approved by the South Dakota State Health Officer and the
Office of the Surgeon General, U. S. Public Health Service.

*Lanham Act project terminated June 30, 1945.

discharge or the urethral meatus appeared abnormal on
inspection.

Males. Specimens obtained from urethral discharge
were used to make smears and cultures. After treatment,
when the discharge was usually absent, the first 10 cc.
of urine immediately after prostatic massage was col-
lected in a sterile centrifuge tube. The urine was centri-
fuged and the sediment cultured. It has been our ex-
perience, and that of others,2 that in this way gonococci
can be found in cases which would otherwise have been
considered cured.

TREATMENT

Choice of Drug. From January 11, 1943, to April 22,
1944, sulfathiazole was used for the initial treatment,
and a second course was given after an interval of one
week if laboratory tests were still positive. If laboratory
tests remained positive after the second course, sulfadia-
zine was given one week later. Complications were prac-
tically nonexistent. In one case with a history of previous
renal disease there was mild hematuria, and in one case
there was moderately severe urticaria which could not be
definitely attributed to the drug. Otherwise, a small
percentage of patients experienced mild nausea.

Beginning May 11, 1944, penicillin was used routinely.
The variation in penicillin dosage reflects the changes
instituted as we learned more about the drug. No com-
plications were noted.

Plan of Administration. Sulfathiazole: A total of

22 grams was given over a five-day period. The first

The Journal Lancet

two doses were two grams each, given two hours apart.
Thereafter, one gram was given every four hours during
the day until 22 grams had been administered.

Penicillin: (1) Three patients sent by us to the U. S.
Public Health Service Medical Center at Hot Springs,
Arkansas, received a total of 60,000 units in 10,000-unit
doses. (2) Sixty-one patients received 150,000 units.
Of these, 32 received 20,000 units every three hours for
seven doses, the last dose 30,000 units; 21 received 50,000
units every two hours for three doses; and 8 received a
single injection of 150,000 to 200,000 units of penicillin
in peanut oil and beeswax. (3) Three patients received
200,000 units in four equally divided doses at two-hour
intervals. (4) Two patients received 100,000 units of
penicillin containing 15 to 25 per cent of X-substance
(Lederle) in three equally divided doses at two-hour
intervals. Failures were retreated with 300,000 units of
penicillin.

POST-TREATMENT OBSERVATION

Sulfathiazole. Before a patient was discharged as
cured, observation was required for a three-month period
after treatment. During this time six smears and cul-
tures were taken, the first four at weekly intervals, and
the fifth and sixth at monthly intervals (in females, pref-
erably just after cessation of menstruation) . If smears
and cultures of all these examinations were negative the
patient was considered cured, provided, of course, phys-
ical examination was negative. The logic and necessity
of these prerequisites for cure are attested to by the work
of Koch et al ,3

Our records show the difficulty of holding patients for
a three-month period. Because of lack of facilities and
desire for economy on the part of the city and county
governments, a compromise had to be reached. There-
fore, when patients had to be confined it was decided
that a minimum of four consecutive negative cultures at
weekly intervals would be required before they were
released. Those who remained in this vicinity were kept
under observation for the rest of the three-month period.
However, many of our patients were transients and left
this area immediately upon release. No patient was ever
discharged as cured unless the six negative cultures over
a three-month period were obtained. Those who left
before they had been observed for the desired period
were warned that they could not be certain of cure and
were advised to seek further tests until three months had
elapsed.

Penicillin. The favorable results which had been re-
ported, 4'5>G'7 with this drug by the time we instituted
routine penicillin treatment (May 11, 1944) caused us
to modify the post-treatment quarantine requirement.
Since well over 90 per cent of cases were reported cured
after treatment with 150,000 units of penicillin, it was
felt that involuntary confinement for four weeks after
this type of treatment constituted an unjustifiable ex-
pense to the authorities, as well as an unwarranted in-
fringement upon the freedom of an overwhelming ma-
jority of the patients. Therefore, those patients who had
to be confined were released if six negative smears and
cultures, taken every other day after treatment, were
negative. However, except for those who left town,

additional smears and cultures were taken at weekly in-
tervals until one month after treatment and repeated at
monthly intervals, whenever possible, until three months
had elapsed from the time treatment was received.

Analysis of Results

SULFATHIAZOLE

Fifty-nine (79 per cent) of this group of 75 cases
(66 females, 9 males) were rendered negative while
under our observation. Fifty-one (68 per cent) were
negative after a single five-day course of therapy. Eight
required two or more courses. Sixteen cases (13 females,
3 males) remained positive in spite of repeated treatment
(as many as six courses in some cases). Most of these
patients were confined in the Black Hills Rapid Treat-
ment Center. The others had opportunities for re-
exposure, which they all denied. Reinfection was consid-
ered and in each case was decided to be very unlikely,
although it could not be definitely ruled out.

Despite our aim to observe all patients for three
months after treatment, we were unable to follow the
majority of cases for that length of time, owing to cir-
cumstances beyond our control. The duration of obser-
vation for the 59 patients considered cured is shown in
Table 1.

Table 1

Duration of Observation of 59 Patients
Treated with Sulfathiazole

DURATION OF
OBSERVATION

NUMBER OF NEGATIVE SMEARS
AND CULTURES

NUMBER OF
PATIENTS

3 months

2 months

1 month

3 weeks

2 weeks

The 16 patients who were treatment failures and the
eight patients who required more than one course of
therapy before being rendered negative received a total
of 74 courses of treatment. If we exclude the last course
in each of the eight patients who finally became nega-
tive, we have 66 courses of treatment, which were fol-
lowed by positive bacteriological findings. Table 2 shows
the various times at which these positive findings were
first discovered during the post-treatment period.

Table 2

Time of First Positive Findings after Treatment

TIME OF TEST

AFTER TREATMENT

WEEK

WEEKS

MONTHS

Test

i§

PENICILLIN

All 69 patients (55 females, 14 males) in this group
were rendered negative while under our observation.
Sixty-six (96 per cent) were rendered negative after
initial treatment and were observed as shown in Table 3.

March, 1946

Table 3

Duration of Observation of 69 Patients
Treated with Penicillin

DURATION
IN W2EKS

AVERAGE NUMBER OF NEGATIVE
SMEARS AND CULTURES

NUMBER OF
PATIENTS

12 or more

Less than 1

Seven patients were found to be positive after the first
course of treatment, but four of these were considered
to be reinfected, since three admitted re-exposure and
the fourth, whose denial of re-exposure was doubted, had
been negative for 69 days after treatment. Table 4 gives
the data concerning these four patients.

The three patients who were considered as failures
after the first course of treatment were rendered nega-
tive after retreatment with 300,000 units of penicillin.
The data are given in Table 3.

Table 4

Data on Patients Considered Reinfected

AGE

SEX

INITIAL

TREAT-

MENT

TIME

NEGA-

TIVE

(weeks)

NO.

TESTS

RE-EX-

POSURE

RE-

TREATED

WITH

FURTHER
OBSERVATION
TIME NO.

NEGA- OF

TIVE TESTS

150,000
units in
3 doses
q2h

denied

300,000
units in
oil

1 week

“

admitted

“

8 weeks

“

4 days

150,000
units
in oil

2 weeks

Thus 66 (96 per cent) of the 69 patients were ren-
dered negative after initial treatment, and 100 per cent
were negative after retreatment of the three initial
failures.

It should be noted that 33 of the 69 patients in this
group had been resistant to sulfatherapy, and that every
one of the 33 was rendered negative after a single course
of penicillin.

Comment and Summary

Comparison of the efficacy of sulfathiazole and peni-
cillin in the treatment of 144 cases of gonorrhea reveals
that:

1. Sixty-eight per cent of 75 patients were cured with
a single course of sulfatherapy, and on retreatment (2-6
courses) 77 per cent of the total were cured.

Table 5

Data on Patients Considered Failures after First Treatment

AGE

SEX

INITIAL

TREAT-

MENT

TIME

NEGA-

TIVE

(weeks)

NO.

TESTS

RE-EX-

POSURE

RE-

TREATED

WITH

FURTHER
OBSERVATION
TIME NO.

NEGA- OF

TIVE TESTS

150,000
units in
3 doses
q2h

denied

300,000
units
in oil

10 days 5

200,000
units in
4 doses
q2h

denied

4 weeks 5

150,000
units
in oil

3 days

denied

5 weeks 9

2. Ninety-six per cent of 69 patients were cured with
a single course of penicillin, and on retreatment (with
300,000 units) 100 per cent were cured. Thirty-three of
these patients had been sulfa-resistant, and all were cured
after a single course of penicillin.

3. Sulfa-treated patients should be observed for a
minimum of three months before being considered cured.
Table 2 shows how many failures in this series would
have been missed if observations had been terminated
earlier.

4. The number of initial penicillin failures in this
series was too small to afford us any valid idea as to how
long post-treatment observation should be continued rou-
tinely before patients are considered cured. These pa-
tients should, of course, he kept under observation for a
minimum of three months to rule out the possibility of
masked signs and delayed incubation period of concomi-
tant syphilis.8

References

1. Carpenter, Charles M.: Laboratory procedures in the diag-
nosis of gonorrheal infection. Ven. Dis. Inform., 24 : 1 3 3—43, 1 943 .

2. Sewell, George, Salchow, P. T., and Nelson, E. A.: Com-
parison of results obtained with culture of urine and urethral secre-
tion in the detection of gonorrhea. Ven. Dis. Inform., 24:218—21,
1943.

3. Koch, R. A., Mathis, E. N., Geiger, J. C.: Criteria of cure
in gonorrhea. Ven. Dis. Inform., 25:25—41, 1944.

4. Mahoney, V. F., Ferguson, Charles, Buchholtz, M., and

Van Slyke, C. V.: The use of penicillin sodium in the treatment

of sulfonamide-resistant gonorrhea in men. Am. J. Syph., Gon.,
and Ven. Dis., 27:525-28, (Sept.) 1943.

5. Turner, T. B., and Sternberg, T. FI.: Management of

venereal diseases in the army. J.A.M.A., 124:133—37, (January
15) 1944.

6. Cohn, Alfred, Studdiford, William E., and Grunstein, Isaak:
Penicillin treatment of sulfonamide-resistant gonococcic infections.
J.A.M.A., 1 24:1 124-25, (April 15) 1944.

7. Ferguson, Charles, and Buchholtz, Maurice: Penicillin ther-

apy of gonorrhea in men. J.A.M.A., 125:22—23, (May 6) 1944.

8. Walker, A. E., and Barton, R. L.: The treatment of gon-

orrhea with penicillin during the incubation period or early phase
of syphilis. Ven. Dis. Inform., 26:241—44, 1945.

The author acknowledges with gratitude the valuable assist-
ance of Ellen B. Donovan, Supervisor of Nurses, Pennington
County Health Department.

In a study of the treatment of experimental rabbit syphilis, it was found that small frac-
tions of the curative doses of penicillin and mapharsen administered together were not only
curative but were therapeutically more effective together than might be expected from the
additive effect of the quantity of the drugs administered. It was concluded, therefore, that
penicillin and mapharsen act synergistically. — Eagle, Magnuson, and Fleischman, "The
Synergistic Action of Penicillin and Mapharsen (Oxophenarsine Hydrochloride) in the Treat-
ment of Experimental Syphilis,” ]. Ven. Dis. Inform., 27: 3-9 (January), 1946.

The Journal Lancet

Electroshock Convulsion Therapy

W. E. Olson, M.D.

Fort Meade, South Dakota

EVEN coroners’ juries realize that suicide is a risk
of mental disorder. What is less frequently real-
ized is that mental patients do not commit suicide
because of some mysterious law of nature, but quite
simply because they are so miserable that they would
rather be dead. There are few patients suffering from
organic diseases, even from an incurable cancer, who ever
feel as badly as that. Yet the relief of such conditions
is sometimes not thought worth even the risk of a pain
in the back. In a true perspective mental disorders would
be seen for what they are — as potentially destructive of
human life as a malignant growth, and far more terrible
in the suffering they may cause. Their treatment is
worth risks, even when it is a matter of cutting short
the duration of an illness when the patient can eventually
be expected to recover naturally.

Among such types of treatment convulsion therapy oc-
cupies a principal place. As long ago as 1798 Weichardt
recommended the giving of camphor to the point of
producing vertigo and epileptic fits, and other physicians
have followed his example. The treatment was revived
by von Meduna, who in 1933 recommended the intra-
muscular injection of a 25 per cent solution of camphor
in oil to schizophrenic patients. Camphor was later re-
placed by more efficient drugs which could be given
intravenously, or which would for other reasons produce
a fit more rapidly. These drugs included cardiazol, tria-
zol, and picrotoxin. Finally, Cerletti and Binni in 1937
produced therapeutic fits by passing an electrical current
through two electrodes placed on the forehead, and a
comparatively safe, convenient, and painless method of
convulsion therapy was made available.

Indications for Such Treatment
Schizophrenia. This treatment, which was first used
for schizophrenia, has found its most useful application
in depressive states. The early satisfactory results in
schizophrenia, some of them brilliant, have not been
maintained. The chief effect of convulsion therapy in
schizophrenia is symptomatic. For instance, even a single
therapeutic convulsion may relieve catatonic stupor, but
the patient, though no longer stuporous, may be left
deluded and hallucinated or switched into a catatonic
excitement; or the stupor itself may return after a short
time. Symptoms of anergia and depression are fre-
quently susceptible to benefits from convulsion therapy.
As these symptoms are often prominent in schizophrenia
and do not always disappear when the underlying proc-
ess has been halted by insulin therapy, the role of con-
vulsion therapy in schizophrenia is a definite, if not a
large, one.

Confusional episodes that may occur in schizophrenia
may also react to convulsion therapy, but they are vir-
tually always a sign that the schizophrenic process is in

Read before the Black Hills District Medical Society, Dead-
wood, South Dakota, November 29, 1945.

an active stage and in need of a more radical therapy.
In general, the schizophrenic symptoms that benefit from
convulsion are affective ones, and when a patient is re-
tarded, apathetic, listless, and lacking in interest because
of an existing, even if unrecognized, state of depression,
the treatment may produce useful results.

Such conditions are, however, even more often due to
a blunting or washing away of normal affectivity, and
then no benefit will be obtained. For this reason the
common hebephrenic type of schizophrenia has proved
entirely refractory to convulsion therapy. In general it is
of little service to hammer away at the patient with re-
peated convulsions if worth-while benefits are not ob-
tained from the first few fits. Long series of convulsions
may produce an even greater degree of deterioration
than already exists.

The useful indication of what may be obtainable with
convulsion therapy is given in schizophrenia, as in other
states, by an intravenous injection of sodium amytal.
This drug temporarily abolishes higher cortical inhibi-
tions, and the potential and more permanent state of
affairs may then be revealed.

Despite its limitations convulsion therapy remains a
useful agent. An improvement that results in removing
a catatonic schizophrenic from a seclusion room and put-
ting him to work on the farm is well worth achieving.

Involutional Depression. From their use in schizophre-
nia convulsions came to be tried in depressive states, and
here the results were even more brilliant and have stood
the test of time. Of all depressive syndromes those of
later life react best. These states, which are of obscure
etiology, are probably a clinical entity distinct from the
true manic-depressive psychoses. The underlying bodily
and mental constitution is different. Whereas in the
manic depressive one finds most typically a pyknic hab-
itus and a cyclothymic temperament, in the involutional
depressive one finds more commonly an asthenic habitus
and a rigid, obsessional type of personality. In the manic-
depressive syndrome the depression may come on rapidly,
even abruptly. In involutional melancholia symptoms
appear and progress very gradually and insidiously. The
picture at first presented is one that used very frequently
to be called neurasthenia, in which the patient is chiefly
conscious of a failure of interest, inability to concentrate,
and a gradually increasing incapacity for all the ordinary
affairs of life. These symptoms, with an intractable in-
somnia and progressively deepening depression, lead to
the full-blown picture of mixed agitation and retardation
with hypochondriacal preoccupation, ideas of guilt, and
delusions.

Convulsion therapy has proved our most powerful
weapon in the treatment of such states, and recoveries
of 70 to 90 per cent are constantly being reported. This
recovery rate represents a great achievement, for these
states were previously very refractory to treatment.

March, 1946

Although there was a natural tendency for the illness
to remit, it seldom ended spontaneously in less than six
months, and often lasted one or two years, or even drift-
ed on into a chronic melancholia. In addition, the risk
of death from exhaustion, intercurrent disease, and, in
the acute phase, suicide, was far from negligible.

Such states, once recognized, should be attacked early.
In the early stages these patients can be readily treated
in a psychiatric ward in a general hospital if they are
promptly brought under treatment and if the risk of
suicide is not too great. As the illness advances, the
physical state of the patient deteriorates and he becomes
less well able to stand the strain of treatment. The
longer the patient is away from work the more difficult
it will be to get him back to it, and, finally, the sooner
one begins treatment the more months of misery the
patient will be spared. Of course, not every middle-aged
patient complaining of worry, insomnia, and similar
symptoms should be operated on with convulsion therapy
at the first interview, but after the case has been fully
explored and its endogenous nature has become clear,
and when symptomatic treatment has proved of little
avail, further time should not be wasted.

M anic-Depressive Syndromes. In depressions of earlier
life, particularly before the age of 40, one should be
rather more cautious. The phasic changes of the manic
depressive may be very troublesome to treat. It is a
more frequent event in this type of illness for a depres-
sion relieved by convulsion therapy to pass over into a
temporary hypomania that may prove even more difficult
to manage socially. Or the depression may lift, but only
temporarily, and then relapse again whenever treatment
is intermitted.

The swings of mood of the manic depressive may be
endogenously determined and dependent on biochemical
changes that are at present beyond analysis and control.
They certainly seem to be more resistant than involu-
tional depression to a treatment which, though powerful,
is still symptomatic. Furthermore, the spontaneous re-
covery of the true manic depressive may be awaited
much more hopefully than that of the involutional
patient.

Manic States. The treatment of manic states, that is,
the acute manias, by convulsion has produced varied re-
sults. Different authors claim different percentages of
success, and the treatment is not so efficacious as in de-
pressive states. Many states of acute excitement in young
people which clinically closely resemble true mania prove
eventually to be schizophrenic, and it is well to be on the
lookout for schizophrenic symptoms, so that insulin
therapy may not be unnecessarily delayed.

Risks and Contraindications to
Convulsion Therapy

It can hardly be overemphasized that convulsion ther-
apy is a surgical treatment in psychiatry and that the
general rules governing the admissibility of surgical in-
tervention apply. While operation should not be unnec-
essarily delayed, it should not be undertaken in a light-
hearted spirit and should never be employed as a mere
placebo.

When convulsion therapy is decided upon the patient
should be examined carefully to exclude exceptional dan-
gers. The position should be explained both to him and
to his relatives, and the permission of both should be
sought. Finally, every method should be used to mini-
mize the risk, which can never be entirely excluded. The
risk of death from convulsion therapy is negligible.
Actual figures are hard to obtain, but the rate is prob-
ably below one in a thousand and is comparable to that
of giving a general anesthetic without other operative
procedure. Death occurring during a fit is usually due
to acute cardiac decompensation. One will therefore
beware of giving the treatment when the heart is already
overburdened. An electrocardiogram is a very useful aid
to decision.

Caution is necessary, but it is possible to be over-
cautious. In the American medical literature there are
reports of the successful treatment of patients as old
as 75. Senile depressions and confusional states may
respond well to electroshock therapy if the illness is not
accompanied by persistent high blood pressure. Patients
with angina, recovered coronary thrombosis, and even
existing heart failure have been treated, but in such cases
the therapist is taking his patient’s life in his hands, and
the risk is such as few would care to take unless the
patient’s mental condition is desperate and the prospect
of relief by other methods is negligible. Where existing
myocardial disease is found one cannot expect the treat-
ment to be of any benefit to the heart.

The most frequent risk to be faced with convulsion
therapy is that of fracture, particularly compression frac-
tures of the vertebral bodies. At first such vertebral frac-
tures were judged to be a serious complication and a
definite contraindication to the treatment, but they are
no longer considered so. These fractures are usually
symptomless, and even when they do cause some disa-
bility it is usually limited to slight pain in the back,
which passes off after a few months.

The usual sign of such fractures, apart from routine
X-ray, is a pain in the back, which may also be referred
to the chest. A few patients will say it is really severe,
but it lessens in a few days, and gradually in succeeding
months it may diminish to an occasional twinge when
heavy work has to be undertaken. Unfortunately, those
patients who are most disabled by its occurrence are most
liable to it; that is, muscularly well-developed manual
laborers and athletes. Other fractures that may occur
during treatment are of the upper part of the humerus
and femur. Dislocation of the jaw or shoulder may also
occur, especially in people who have had such accidents
before.

Memory disturbances are very common, especially in
elderly people with hypertension. Sometimes they will
take on an acute aspect and be of fairly severe degree,
when the patient will be precipitated into a temporary
confusional episode. A vexatious complication of con-
vulsive therapy is translation of the depression into
mania or hypomania. This complication is most fre-
quently seen in the manic-depressive syndrome; it rarely
occurs in involutional melancholia. When it occurs no
harm is done, but the social aspects of treatment are

The Journal Lancet

altered and admission to a mental hospital may become
imperative.

Time to Begin and Length of Treatment

Different rules apply to the beginning of treatment in
manic-depressive and involutional depressions. In the
manic-depressive group one is usually well advised to
put off treatment for a time, as spontaneous recovery,
when it occurs, is more likely to be lasting than improve-
ment brought about by convulsions. In the meantime
the patient is carefully watched for any degree of deep-
ening of the depression, the appearance of suicidal risk,
and indications that it will be difficult to look after him
at home.

While the patient holds his own it is as well to post-
pone convulsion therapy. If, however, he begins to go
downhill, one should step in before future need for ad-
mission to a mental hospital has become probable. In
the involutional depressions the earlier treatment is
begun, as a rule, the better. Although, as has been said,
spontaneous recovery does occur, it often arrives late —
too late to salvage the wreck of the patient’s life.

When the patient first comes for diagnosis he has
probably been ill for months and has struggled in vain
against his mounting difficulties. These patients, by rea-
son of their rigid and obsessional personalities, usually
do not give in at all until they are far gone in the illness.
Further waiting for spontaneous remission is needlessly
painful and is contraindicated by the probable deteriora-
tion of the physical condition. The chances of rapid im-
provement are much better when the patient’s physique
is still fairly well preserved than when he has become
thin and feeble.

The social aspects of illness can never be forgotten in
psychiatry. Such considerations as the available amount
of sick leave, the imminence of compulsory pensioning
or dismissal on medical grounds, and the capital available
have all to be taken into account.

A good clinician will govern his treatment by his in-
creasing knowledge of how the patient reacts. The aim
will be to give as few and infrequent treatments as are
sufficient to produce a progressive change for the better.
A patient will report that for three days after a treat-
ment he feels much better, but then it all comes back.
In such cases treatments twice weekly may well be re-
quired to get maximum benefit. Other patients will react
more slowly and will report that for a day or so after
the treatment they feel muddled and unable to concen-
trate, that they then begin to feel better, and a week
later find themselves still improving. With such patients
a much slower tempo will very likely prove best. As has
been emphasized, signs of any gross or continuing mem-
ory disturbance or confusion should lead to an inter-
mission for a time.

Technique of Treatment

The patient receives no breakfast on the morning of
the treatment. - He is brought to the treatment room in
pajamas. Before entering the treatment room the patient
must empty his bladder and remove false teeth or other
objects from the mouth. It the patient is apprehensive
and premedication is necessary, one of the most satisfac-
tory ways is to give a small dose, 2 to 3 J4 grains, of

sodium amytal intravenously just before treatment is
started. This sedative produces sufficient relaxation with-
out necessitating any great increase in the voltage re-
quired to produce a fit.

The treatment is given on a hard but padded couch
or table. The patient lies on his back on the table with
a firm pad or sandbag beneath the dorsal vertebrae and
a small, low pillow for the head. The aim is to provide
support for the spinal column and the head and a con-
siderable, but not excessive, degree of hyperextension of
the back.

Control of the patient’s movements during the con-
vulsion is essential if fractures are to be avoided. The
patient can be held down by a trained staff of attendants.
One holds the feet in close abduction; one applies weight
to the pelvis, pressing it firmly to the table; two more
stand on each side of the shoulders, and, with their
weight transmitted through their forearms, keep the
shoulders pressed to the table. The patient’s arms are
kept close to the side of the body and the forearms are
crossed across the chest and maintained in that position
during the convulsion.

The electrodes are applied to the forehead. A contact
jelly is used to reduce surface resistance. A rubber
mouth gag is used to prevent injury to the lips or
tongue. The nurse at the patient’s head holds the mouth
gag in place. The patient’s chin is held firmly up on
the gag so that the jaw cannot open far enough in the
initial stage of the fit to risk a dislocation. The resist-
ance is measured. The voltage, electrical current, and
time of application are all accurately set. The doctor
glances around to see that all are in position, gives the
word of warning, and then presses over the switch.

An insufficient voltage will produce only a subshock;
that is, momentary loss of consciousness but no convul-
sion. Several of these subshocks given at one session will
sometimes produce cardiac irregularities, and the patient
may appear to stop breathing and collapse. Breathing
may be re-established by pressure to the thorax, and the
patient will generally rally in a minute. Nevertheless,
too many of these subshocks at once are to be avoided.

With the electroshock therapy equipment used at
Fort Meade, the usual beginning voltage is either 120
or 130 volts. The usual starting time is two tenths of
a second. The current is 1000 milliamperes. If this
dosage fails to produce a convulsion the voltage can be
raised to 130 or the time to three tenths of a second.
During the course of treatment the voltage may have
to be raised to as high as 170 or 180 volts, the time
to four tenths or five tenths of a second, and the cur-
rent up to 1250 or 1500 milliamperes. Evidently the
margin between the shock dose and the lethal or dan-
gerous dose is very wide.

All the time the fit is going on the movements are
controlled. The most important part of this control is
taking the strain of the initial jerk on the back and pre-
venting flexion of the back. If breathing does not com-
mence soon after the convulsion a few rhythmic compres-
sions of the chest will cause it to start. After the patient
has taken several deep breaths he is put on the surgical
cart and taken to the recovery room, where he is placed

March, 1946

in bed. In some cases there is a struggling and restless
phase during which the patient requires manual restraint
for a few minutes.

When possible the physician should try to observe the
patient during the postconvulsive stage, for his behavior
at that time is often illuminating and may clear up a
doubtful diagnosis. The true depressive generally re-
mains quiet and pleasant as he comes round; the unsus-
pected schizophrenic may exhibit suspicious and aggres-
sive behavior and typical mannerisms.

After half an hour to an hour the patient is usually
able to get up. However, there may be some memory
loss for several hours, and it is desirable that he should
be kept under some supervision for the rest of the day.
Not infrequently there is a good deal of headache.

Complications and Special Measures

When insomnia is being treated sedatives such as bar-
bital may be prescribed the night before, but sedation
may necessitate a slight increase in the voltage required
for a convulsion. Bromide should not be given.

One risk of electroshock therapy is that of fracture
of one or more bodies of spinal vertebrae. This risk is
very much lessened when the patient is carefully placed
and restrained during the convulsion. At the Fort Meade
Veterans Hospital intocostrin has been used in certain
cases for the purpose of preventing spinal fractures or
other fractures or dislocations. Intocostrin is a physiologi-
cally assayed preparation of curare, adjusted in strength
to conform to the equivalent of 20 mg. per cc. of a
standard drug. When used to soften convulsions in
electroshock therapy the dosage of 0.5 mg. of into-
costrin per pound of body weight is an average dose.
Nevertheless, as a precaution, a dose of 20 mg. less than
this should be employed initially. Intocostrin should be
administered as a uniformly sustained intravenous injec-
tion over a period of one to two minutes, preferably two
minutes. Rapid injection is dangerous. After the into-
costrin injection has been given one should wait at least
two minutes, until the patient can barely lift his head,
before giving the shock. The dosage recommended is
sufficient for persons with weak musculature. If the esti-
mated dose fails to produce paralysis, another full para-
lyzing dose cannot be given within 24 hours.

One to two minutes after the injection of intocostrin
the physiological curarization effect begins. The patient
first complains of haziness or fuzziness of vision. Next,
bilateral ptosis appears, with slight nystagmoid move-
ments, relaxation of the face, and heaviness with relaxa-

tion of the jaws. At this point the patient complains of
tightness of the throat and huskiness of the voice. Last
to appear is shallowness of respiration, from weakness of
the intercostal and diaphragm muscles. Shock is insti-
tuted at the peak of curarization. The curare effect
slowly recedes and seems to disappear in 15 to 20 min-
utes.

By the time the patient regains consciousness from
shock therapy the effect of curare has disappeared. If,
after the shock treatment, the physician is at all con-
cerned about the ptosis, the tongue, or the ability to re-
cover from the paralysis, I cc. of prostigmine, 1:2000,
can be given intravenously. If respiratory failure occurs
artificial respiration should be instituted. Since the ex-
cretion of the drug is rapid, patients under artificial res-
piration spontaneously regain breathing power within a
short time. There is no increased tolerance to repeated
doses of intocostrin.

Electroshock therapy has been used rather extensively
at Fort Meade Hospital. The first treatment was given
on June 26, 1945, and since then 38 patients have been
treated or are under treatment. A total of 739 treat-
ments have been given, with 649 grand mal and 90 petit
mal reactions. A total of 256 intocostrin injections have
been given to these patients.

Thus far five patients have recovered sufficiently to
be discharged from the hospital. Several others have im-
proved sufficiently to consider their discharge from the
hospital, and probably will be discharged in the near
future. Most patients who receive the treatment are able
to make a much better hospital adjustment as a result
of the treatment, even when they do not improve suffi-
ciently to leave the hospital. For instance, they are more
pleasant in their attitude, take a more normal interest in
their surroundings, and usually feel better physically,
eat better, and tend to gain in weight.

Schizophrenic patients tend to relapse when the treat-
ments are stopped and present a problem in manage-
ment. Quite a few such patients are carried on mainte-
nance doses, that is, they receive one or two treatments
a week, or possibly a treatment every ten days. We have
found that hebephrenia is resistant to treatment, and
that patients with marked paranoid delusions, suspicious-
ness, and so forth, react rather poorly to treatment.

In summary, from our experience with electroshock
therapy at Fort Meade we are definitely of the opinion
that it is a valuable aid in the treatment of psychiatric
cases. In a number of cases the result has been very
gratifying.

By 1940 another advance in the so-called shock therapies, the electroshock of Cerletti
and Bini, was coming into general use. By means of electricity convulsive seizures similar to
those of metrazol but somewhat milder were induced. These proved equally effective and had
the advantages of causing less apprehension in the patient and of avoiding the necessity of
repeated intravenous injections. Whereas in the beginning we had hesitated to treat patients
over 40 with convulsive therapy, the age limit was gradually raised until we were treating
patients in the seventies and even eighties, using curare where indicated in the aged or debili-
tated.— C. W. Osgood, M.D., in Wisconsin Medical Journal, May 1944.

The Journal Lancet

AMERICAN STUDENT HEALTH ASSOCIATION NEWS LETTER

ANNUAL MEETING, AMERICAN STUDENT HEALTH ASSOCIATION, HOTEL NICOLLET,
MINNEAPOLIS, MAY 8-9, 1946. HOST: UNIVERSITY OF MINNESOTA

Dr. George T. Blydenburgh, Secretary-Treasurer of the American Student Health Asso-
ciation, directs attention to the following articles on the tuberculin test and the chronic cough,
by Dr. Sydney Jacobs of Tulane University, as providing useful summaries of information
on these problems.

THE TUBERCULIN TEST*

By Sydney Jacobs, M.D.

Prior to the isolation of tuberculin by Robert Koch
in 1890 it was seldom possible to detect tuberculous
infection before the body was hopelessly involved by the
disease. With this agent, an exquisitely sensitive means of
determining the presence of tubercle bacilli was at hand.

The word "tuberculin” originally designated the fluid
medium in which tubercle bacilli had grown while liber-
ating tuberculoprotein, but at the present time it is ap-
plied to any material — other than living tubercle bacilli —
that contains tuberculoprotein. There are accordingly
many different types of "tuberculin”, but only two are
in common use. These are O.T. (Koch’s Old Tubercu-
lin), the fluid medium from which tubercle bacilli have
been removed by filtration, and P.P.D., a standardized
purified protein derivative of tuberculoprotein. P.P.D.
is prepared as a weaker "First Strength” tablet and a
stronger "Second Strength.” O.T. is available as a
liquid, 1 cc. being the equivalent of a gram.

Although there have been many different technics for
performing the tuberculin test, the intradermal adminis-
tration is by far the most common. Where it is not pos-
sible to retest individuals many times, the proper prac-
tice is to begin with either 0.01 mg. O.T. or first strength
P.P.D., and to retest all those negative to that dose with
1.0 mg. O.T. or second strength P.P.D. A very small
percentage of persons will react to the intradermal in-
jection of not less than 10 mg. O.T. For all practical
purposes, we may disregard this small percentage and
utilize only the two doses, regarding all persons as being
insensitive to tuberculin when failing to react to either
1.0 mg. O.T. or second strength P.P.D.

If the individual has already developed hypersensitivity
to the tubercle bacillus, within forty-eight to seventy-two
hours after the intradermal injection, the test will be
positive; i.e., a zone of well-defined inflammation will
appear at the site of injection. The inflammation does
not start at once (in contrast to the type of reaction fol-
lowing intradermal injection of pollens or other aller-
gens) but some hours later. It increases during the first
twenty-four hours and is quite evident at the end of
forty-eight to seventy-two hours. Depending on the
severity of the reaction, several days or weeks are re-
quired for the complete disappearance of the cutaneous
inflammation. The lesion is a hyperemic indurated area
one or more centimeters in diameter; in rare instances

•Reprinted from the Bulletin of the Tulane Medical Faculty,
Vol 4. No. 4 (August 1945), with the permission of the author.

the inflammation may actually proceed to the point of
ulceration and slough formation in highly sensitive per-
sons. As a result of faulty technic (and this is extremely
unusual) some tuberculin may escape into the blood
stream to give rise to a focal or systemic reaction, but
this reaction occurs only in individuals of very high sensi-
tivity and as a rule is not of serious consequence. In
New Orleans, where many thousands of tests have been
performed, not once has a serious ill-effect been recorded
as following the intradermal use of tuberculin.

According to our present concepts, a tuberculin test
can be positive only if tubercle bacilli grow in the body
and elaborate tuberculoprotein, thereby maintaining a
state of hypersensitivity toward the tubercle bacillus.
This test tells us whether there are living tubercle bacilli
in the body; it does not tell us whether these tubercle
bacilli are free in areas of "active” disease or incarcer-
ated in healed lesions or calcified lymph nodes. In post-
mortem studies, Robertson found viable acid-fast bacilli
in the tracheobronchial nodes of many subjects who died
of nontuberculous disease and whose only evidence of
tuberculosis was a positive tuberculin test. In a small
group of well-studied children, the tuberculin test has
become negative after having been positive; this has co-
incided with an extreme degree of calcification of lymph
nodes. This is taken to mean that the tubercle bacilli
in these areas have been killed and therefore no longer
elaborate tuberculoprotein to sensitize the body, conse-
quently hypersensitivity to tuberculin disappears.

Who Has a Positive Test?

In 1907, Pirquet and Hamburger tested the children
living in the slums of Vienna; 95 per cent of them
reacted positively to tuberculin. Since that time, the
remarkable public health campaigns of this century have
reduced the incidence of tuberculous infection greatly.
At the Mayo Clinic in 1932, children of all ages were
tested, only 16 per cent reacting positively. Elsewhere,
in a similar age group, 75 per cent were positive. Because
of this great disparity, Chadwick and Johnston have
cautioned against accepting any single figure as indica-
tive of the true state of affairs; they have pointed to the
fact that surveys conducted in different portions of any
city have indicated a wide range of incidence of posi-
tivity. One of the largest surveys of the country (the
Framingham, Massachusetts, ten-year plan) included
more than 100,000 determinations on children of all
ages; 28.5 per cent of these reacted positively. In New
Orleans, the average figure for school children was in
1944 between 30 and 33 per cent of those tested.

March, 1946

Who Has a Negative Test?

We may state that all those who do not harbor viable
tubercle bacilli in their bodies will react negatively to
tuberculin. This applies to that large group who have
never been infected and to that very small group with
"burn-out” infection. Although it is ordinarily believed
that practically all adults react positively and therefore
that no adults are tuberculin-negative, this is not so. The
number of adults who have never been infected with
tubercle bacilli is steadily mounting; we may expect it
to increase concurrently with the improvement in living
conditions. Recent surveys indicate that some pulmonary
parenchymal calcifications (which have always been re-
garded as evidences of tuberculous infection) may be
caused by such nontuberculous factors as histoplasma
and ascaris infestations. In the process of differential
diagnosis, we are helped considerably when we can dem-
onstrate that the patient is insensitive to tuberculin. One
should therefore not assume that every adult reacts posi-
tively to tuberculin.

In recent years, much interest has been manifested in
an unusual form of pulmonary disease, sarcoidosis, which
is believed by some authorities to represent a noncase-
ating phase of tuberculosis. In most patients with sar-
coidosis, the tuberculin test is negative and no tubercle
bacilli are found in the sputum. In some instances, the
subjects have been observed to change from a state of
being tuberculin-negative to one of being tuberculin-
positive and coincidentally the pulmonary lesions under-
go caseation with the appearance of tubercle bacilli in
the sputum.

Considerable emphasis has been placed on the sup-
posed fact that the tuberculin test is negative in far
advanced tuberculosis and during the course of inter-
current exanthemata such as scarlet fever and measles.
At the Charity Hospital of Louisiana the members of
the resident staff administer tuberculin routinely to the
several hundred cases of tuberculosis annually admitted.
They have never encountered a genuinely negative tuber-
culin test in the presence of active pulmonary tubercu-
losis. Some investigators have reported that the tubercu-
lin test is rendered temporarily negative when measles
or scarlet fever supervenes, but others have found con-
trary results. Perhaps some of the disparities may be
explained by two factors, one pertaining to the patient,
the other to the tuberculin.

Patients sometimes fail to react to tuberculin (just as,
at the same time, they fail to react to the intradermal
injection of other irritants such as codeine) because of
dehydration; following administration of an adequate
amount of fluid, the tuberculin test becomes positive.
Another frequent source of falsely negative tests is a
tuberculin dilution rendered impotent by age or one
which is too weak for the degree of hypersensitivity of
the individual patient.

Do all Positive Reactors Have Active
Tuberculosis?

The answer to the above question is no. About 60—85
per cent of reactors can be demonstrated to have primary
foci of tuberculosis. These foci are usually pulmonary

but in the majority of instances indicate only a casual
contact with an infectious patient. Only 1-2 per cent
of these reactors ever manifest the disease clinically.
Since there is no way of telling whether a given patient
has the minute, inactive focus carried by so many urban
dwellers or whether he has clinically evident disease, the
presence of a positive tuberculin test is sufficient indica-
tion for a general physical examination including roent-
genogram of the chest. It is to be expected that, as the
incidence of tuberculosis falls, the chance of a casual
contact resulting in tuberculous infection will correspond-
ingly lessen. There will then be fewer adults hypersensi-
tive to tuberculoprotein and the value of the test will be
enhanced. Under such circumstances a positive tuber-
culin test will indicate rather prolonged and intimate
exposure to an infectious patient.

Is the Test Safe?

It may be unequivocally stated that the intradermal
introduction of tuberculin cannot reactivate an old tuber-
culous focus or cause exacerbation of an active lesion.
The human body cannot be sensitized to tuberculin if
no tubercle bacilli dwell in it; therefore repeated tests
are equally harmless to an uninfected person. Occasion-
ally in an extremely sensitive person, a small amount of
tuberculoprotein may enter the circulation and cause
systemic febrile symptoms which usually subside within
forty-eight to seventy-two hours. This represents an
error in the technic of administration and usually has
no lasting effect.

Is It Better to Have a Positive Test
or a Negative Test?

It is frequently stated that the individual who has
hypersensitivity to tuberculoprotein and therefore is sen-
sitive to tuberculin is "immunized” to tuberculosis and
is less apt to develop clinical tuberculosis than the indi-
vidual who is tuberculin-negative. Although much work
has been done on this problem, it has never been clari-
fied. We cannot afford to be dogmatic about this but
we know that hypersensitivity to tuberculoprotein as
indicated by a positive skin test does not protect one
against having clinical tuberculosis. If we believe a
positive tuberculin test to be caused by living tubercle
bacilli in the body, then we must regard this a hazard,
even if a small one. A negative test (with the infrequent
exceptions enumerated) indicates that there are no tu-
bercle bacilli in the body and therefore there is no tuber-
culous infection. Despite the impression that a positive
tuberculin test indicates some degree of protection against
miliary tuberculosis, there is no evidence for this. The
available data can be summarized by the statement that
it is better to avoid infection with tubercle bacilli as long
as this is humanly possible.

Does the Extent of the Reaction to the
Tuberculin Test Indicate the Degree of
Tuberculous Involvement?

The answer to this question is no. At one time it
was thought that a person who reacts violently to tuber-
culin has extensive tuberculous lesions, whereas one with
a weak reaction has little or no tuberculosis. The degree
of inflammation at the site of injection of tuberculin

The Journal Lancet

represents the state of hypersensitivity to tuberculopro-
tein, a characteristic which fluctuates widely and appears
not to be related at all to the degree of involvement.

Practical Values of the Tuberculin Test

1. It indicates the presence or absence of living tu-
bercle bacilli.

2. It aids in the establishment or elimination, of tuber-
culosis as the etiology of a given lesion.

3. In survey work (where it is not feasible to take
roentgenograms of everyone), it "screens out" uninfect-
ed persons.

4. It assists in the examination of "contacts” of
tuberculous persons.

5. It assists in the collection of epidemiologic data.

6. It indicates when an exposed child becomes infect-
ed and points to the source of infection.

THE CHRONIC COUGH*

By Sydney Jacobs, M.D.

Cough is one of the most distressing of those symp-
toms commonly encountered in medical practice.
Meakins 1 investigated 1,000 consecutive cases and found
that in 168 the presenting complaint was a chronic cough.
If one listens to the radio for only a short while and
hears the many advertisements for syrups warranted to
"check” coughs, he can realize that much money is spent
annually in this country for the relief of this symptom.
As in no other instance is the fallacy of self-medication
so amply demonstrated: if cough can be caused by such
diverse things as tumor of the larynx and hysteria,
attempts to use any given medication for all types of
cough are absurd.

Physiological Basis for Cough
Cough is usually regarded as a manifestation of dis-
ease of the tracheobronchial tree, and rightly so. It can
be initiated through reflex action, J volition, experience
or by any combination of these. The reflex may be set
up by stimulation of the laryngeal vestibule, the tracheo-
bronchial mucosa, the pleura and the diaphragm. Any-
thing causing irritation or pressure along the course of
this pathway may incite a patient to coughing. As a
rule, the reflex is started when the secretion of mucus
to the ciliated lining is changed from its normal viscosity.
Regardless of what causes this change in viscosity, the
end result is cough, one of the most protective of all
reflex actions.

It ought to be remembered that cough is a co-ordi-
nated action and that it is designed to engage a maxi-
mum amount of air within the lungs under high pres-
sure, to release it suddenly and to expel it rapidly. The
mechanism of cough may be briefly outlined; the patient
takes a deep breath and the glottis closes while the
thoracic wall descends and becomes fixed; as soon as the
glottis opens, the diaphragm rises in plunger fashion,
its tone counteracting the force exerted by the abdominal
muscles. It will readily be seen that one of the main
functions of the cough reflex is to assist in the regula-

•Reprinted from the Medical Times (October 1944) with the
permission of the author.

tory self-cleansing action of the tracheobronchial tree.
Normally the tracheobronchial tree walls are kept moist
by secretion of mucus by the glands; this is impelled
upwards by ciliary action. If the mucous membrane
lining is dry through reduced secretion of mucus, the
cough will be persistent and productive of little or no
sputum; while if the secretion be abundant, expectora-
tion will be loose and easy.

In this sense, cough has been aptly termed the "watch
dog of the lungs.” Squeezing action of the respiratory
muscles of the chest wall together with bronchiolar peri-
stalsis brings foreign material to the bronchioles so that
it can be swept upward and outward by ciliary action
through the trachea and larynx.

The self-cleansing action of the lungs is materially im-
paired if the cough is rendered ineffective by diminution
in respiratory movements of the chest (paralysis of
muscles, adhesive pleuritis, inspiratory chest pain, pul-
monary fibrosis) which impedes delivery of bronchial
content to the bronchi or by increased viscosity of the
bronchial mucus, which happens in the catarrhal stage
of bronchitis. If these two factors co-exist (notably in
collapse of the lung or in diaphragmatic paralysis) there
will not be sufficient peripheral driving force to propel
the mucus along its proper channel when the patient
coughs; as a consequence the mucus is either unpropelled
or may actually be driven deeper into the lung, causing
additional atelectasis.

A very common error is to regard all coughs as due
to inflammation of the trachea or bronchi. It is, of
course, true that cough is a frequent manifestation of
an acute disease of the lungs, as pneumonia, or a chronic
one like tuberculosis; and not infrequently is an evidence
of bronchitis, acute or chronic. It is likewise true that
a not inconsiderable proportion of those who cough have
no demonstrable disease of the trachea or bronchi; in
them, cough arises from other mechanisms and a differ-
ential diagnosis must be carefully undertaken. Here,
as in so many other analogous situations, there is no
substitute at all for a carefully taken history and a thor-
ough physical examination. Occasionally one can obtain
from the history a few leads which point to the source
of the cough. For instance, an early morning cough sug-
gests an overnight collection of mucus from disease of
some portion of the accessory nasal sinuses; a cough
appearing only on exertion points to myocardial weak-
ness and chronic passive congestion of the lungs; while
a cough associated with change in tone of voice may be
due to laryngitis.

Special Types of Cough

Several special varieties of cough call for comment.
These are:

1. The cough of allergic disease ~ is often a loud
hack which comes in paroxysms and is associated with
other phenomena as allergic facies;4 i.e., flattening of the
malar bones because of underdevelopment of the maxil-
lary sinuses.

2. Inflammation in the nose and throat. Maxillary 5
antral sinusitis is a frequent cause of chronic, protracted
cough. The history of chronic illness is strikingly simi-

March, 1946

lar to that of tuberculosis, and the differential diagnosis
can be accomplished at times with difficulty.

3. Occupational exposure to dusts or the inhalation
of excessive amounts of tobacco smoke. In this connec-
tion, it should be emphasized that far too many times
a chronic cough is facilely diagnosed as a "cigarette
cough” when it is actually due to some organic disease
of the bronchi or lungs.

4. Pressure on the vocal cords by mediastinal masses
or glands or on the recurrent laryngeal nerve may cause
a brassy or hollow cough.

5. The presence of a foreign body in the trachea or
bronchus is always to be suspected. Because some for-
eign bodies are not opaque to the X-ray, bronchoscopic
examination is essential whenever the cause of a chronic
cough cannot be found.

6. Cough as a manifestation of "nervousness” 6 is
exceedingly common. This may be seen as an adapta-
tion to a chronic cough of organic origin, in which
event it represents an introversion or over-compensation.
It may be a form of hysteria superimposed on a specific
organic cough — here the patient coughs in order to give
a substitute vent to his inner repressions. Hysterical
cough is at times a conversion symptom of hysteria.
Again, a patient may have a "tic” cough which is merely
a nonspecific manifestation of uneasiness akin to the
habit of clearing one’s throat. Lastly, it should not be
forgotten that once a patient starts coughing through
"nervousness”, he may actually induce a laryngitis and
continue to cough because of this "organic” state.

7. A hacking, nonproductive cough may follow a
respiratory tract affection, in which instance it is called
an "after-cough” and may continue as an annoyance or
even a detriment. It is so similar to the cough of a
bronchiogenic carcinoma that unless one can be certain
about the diagnosis, bronchoscopic and roentgenologic
examinations of the chest are imperative.

8. Cough is not infrequently a sign of cardiac disease.
In congestive heart failure, there may occur pulmonary
engorgement with bronchiolar or bronchial edema and
transudate. This explains the paroxysmal cough which
at times ushers in the attack of myocardial failure and
may be analogous to paroxysmal nocturnal dyspnea.
Even in the absence of congestive failure, cardiovascular
diseases may be marked by paroxysms of coughing. In
mitral stenosis,' the left auricle presses on the left recur-
rent laryngeal nerve and produces spasm or paralysis of
the left vocal cord with a hoarse or brassy cough. A
similar type of pressure may be caused by aneurysm of
the descending portion of the arch of the aorta.

Treatment of Cough

This is never so important as is determination of the
cause of the cough. Unless it is evident very shortly
that the cough is caused by an acute self-limited disease
of brief duration or by a hopelessly incurable malady,
it is better to concentrate attention on the diagnosis even
at the expense of the finer points of therapy. Once the
diagnosis has been established, symptomatic therapy of
the cough will depend upon whether it is a "useful” 8
or a "useless” cough. It is astonishing how this simple

classification may be of service in determining what sort
of treatment to begin.

A cough is said to be useful when it is needed to
clear some part of the tracheobronchial tree of mucus.
It may be tight, loose or insufficient. A tight cough
must be loosened, and nothing is more effective here
than hydrotherapy. Water is to be given by all avail-
able routes. A tight cough should never be dried up;
to do so is to invite pneumonia. The old-fashioned croup
kettle (or its modern electrical equivalent) is good but
must be employed constantly, not intermittently. If it
is not available, wet sheets can be suspended in the pa-
tient’s room. To loosen a cough, solvent expectorants
are valuable. Ammonium chloride is one of the best of
these but should not be used when acidosis is imminent
or when sulfonamides are being administered. It should
be given every two hours and taken with large amounts
of water. As an indirect alkali, sodium citrate in doses
of 1-2 grams is excellent. Iodides are also of value
where the cough is tight and nonproductive but should
not be administered in the acute stages of bronchitis
because of their irritating properties but should be re-
served for the subacute or chronic stages. If the strain
of coughing causes much pain in the chest, immobiliza-
tion is helpful. Although adhesive strapping is widely
recommended, it has many disadvantages, all of which
can be obviated by use of a tight chest binder. For a
loose cough, it is advised that terpin hydrate be given
in capsules of 0.3 gram every four hours.

A cough is said to be useful but insufficient whenever
a patient cannot cough up the mucus that forms. This
may be due to exhaustion from toxemia or prolonged
bouts of coughing, to carbon dioxide intoxication or to
the excessive use of narcotics. If this phenomenon per-
sists, it may lead to asphyxia. A simple remedy is to
induce pharyngeal irritation with benzoic acid dissolved
in syrup of senega. Very often ammonium carbonate
in anise water with syrup of acacia is effective. At times,
it is essential to increase the depth of respiration by
applying alternate hot and cold compresses to the chest
or by carbon dioxide-oxygen inhalations. Diminishing
the secretion with atropine given parenterally or by the
intravenous administration of hypertonic dextrose is indi-
cated. There are times when nothing other than bron-
choscopy will suffice to save the patient’s life.

A cough is regarded as useless when there is literally
no mucus to be coughed up. One encounters the useless
cough in patients who have mediastinal pressure, as from
aneurysm or mediastinal masses, and in the after-cough
of bronchitis which may be becoming a habit. Here
some form of suppressive therapy is needed. Not in-
frequently the patient can be induced to stop cough by
judicious psychotherapy. If this fails, pharyngeal seda-
tion is usually helpful. Candy, lozenges, plain syrups,
and the like may soothe the throat and stop the cough.
This sort of treatment is especially valuable for the type
of cough made worse by lying down. If it fails, depres-
sion of the medulla by bromides or codeine or opiates
may be invoked to stop a patient from coughing. If the
patient still coughs, it is almost axiomatic that the diag-
nosis of ' 'useless cough” is incorrect.

The Journal Lancet

Bibliography

1. Meakins, J. O.: The Practice of Medicine. St. Louis,

C V. Mosby Company, 1936.

2. Lloyd, M. S.: Cough. Laryngoscope, 52:66—74, (Jan.)
1942.

3. Prigal, S. J . : Allergic cough. Dis. Chest, 8:115—20,

(April) 1942.

4. Marks, M B Cough in the Allergic Child. Arch. Pediat.,
59:697-710, (Nov.) 1942.

5. Whiteside, J D., and Woods, R. R : An Investigation into

the Incidence of Infection of the Maxillary Antra in Patients with
Unexplained Chronic Cough. Irish J. Med. Sc., pp. 12—24, (Jan.)
1942.

6. Fenischel, O.: The Psychopathology of Coughing. Psychosom.
Med., 5:181-184, (April) 1 943.

7. Kleiber, E. E.: Long Standing Productive Cough as Chief

Clinical Manifestation in Mitral Stenosis. A Case Complicated by
Thrombosis of the Left Auricle. Ann. Int. Med., 1 5:899—2 10.
(Nov.) 1941.

8. Fantus, Bernard: The Therapy of the Cook County Hos

pital. The Therapy of Cough I. A M. A., 106:375, (Feb. 1 ) 1 936.

ASSOCIATION NEWS

Dr. Ralph Canuteson of the University of Kansas
Health Service announces two additions to his staff,
namely, Dr. Raymond L. Pendleton and Dr. Monti
Belot. Dr. Pendleton, a graduate of the University of
Kansas School of Medicine in 1939, after serving a
rotating internship and a period as resident physician in
obstetrics at the Watkins Memorial Hospital, entered
the armed services in 1941. On return to civilian status
he started his work with the health service on August
1, 1945. He is married and has three children. Dr.
Monti Belot graduated from the University of Kansas
School of Medicine in 1940. After interning at the
University of Kansas Hospital he took a six-month resi-
dency at Bethany Hospital and was then medical officer
of New York American Aviation until September 1942.
Since then he has been in active military service in both
Alaska and the European Theatre. Dr. Belot is serving
part time in the health service and setting up an outside
practice. He is married and has one child.

The University of Chicago announces that Dr. Dud-
ley B. Reed has retired. The position of director of the
health service has been filled by Dr. Ruth E. Taylor for
the current academic year.

Dr. Joseph E. Raycroft, one of the founders of the
American Student Health Association, is making a slow
but apparently satisfactory recovery from a coronary
thrombosis.

The University of Wyoming reports that Dr. Wini-
fred Ingersoll has become acting director of the student
health service.

The Montana State College at Bozeman reports that
Dr. Carl Hammer has been appointed physician in
charge of their student health service. Before joining the
army in 1942 Doctor Hammer had a general practice
in Oxford, Michigan.

Capt. Glen E. Galligan is returning to his position as
director of student health service at Winona State
Teachers College, Winona, Minnesota. Dr. Galligan
has been in military service since August 1944, and
recently has been serving as Chief of the Reconditioning
Service at De Witt General Hospital, located at Auburn,
California. This division is made up of four branches:
Physical Reconditioning, Occupational Therapy, Infor-
mation and Education, and Separation Classification and
Counseling.

The New Jersey College for Women reports that Dr.
Harold W. Potter has been appointed college physician.

Dr. Robert R. Snook, acting director of the depart-
ment of student health at Kansas State College, reports
that the director of that deparment, Dr. Husband, has
been in the Navy since July 1944, and overseas since
September 1944.

Dr. E. Herndon Hudson has returned to his position
as director of the health service at Ohio University,
Athens, after rendering significant service in the Navy.
Using his experience with tropical diseases, he taught
at Bethesda Hospital in Maryland, and there wrote a
concise, accurate, and easily understood pamphlet on
tropical diseases.

The University of New Hampshire reports that Dr.
Walter Batchelder has been appointed university physi-
cian. Dr. Batchelder is a graduate of the University of
New Hampshire and Boston University Medical School.
Before his appointment he had served overseas as a
Major in the Army Medical Corps.

Lehigh University announces that Dr. Carl O. Keck
has been appointed director of the student health service,
to take the place of Dr. R. C. Bull, recently retired.

Dr. Harold D. Cramer, director of the student health
service at the University of Idaho, was wounded in
France while serving as battalion surgeon in the Armored
Division of the 7th Army. He has been convalescing at
the Dibble General Hospital, Menlo Park, California.
While there he has been helping on the plastic surgery
service.

Dr. Max L. Durfee found that living in the college
infirmary was not a satisfying way to solve the housing
situation at the University of Oklahoma. He solved his
problem by returning to his former position at Iowa
State Teachers College, Cedar Falls.

Dr. Dana L. Farnsworth has returned to Williams
College to resume his position as director of the depart-
ment of health. Dr. Farnsworth has been Commander
in the Navy Medical Corps. During Dr. Farnsworth’s
absence Dr. Kenneth McAlpin was in charge of the
department.

Dr. Frank P. Mathews, recently released from the
Navy after four years’ service, has been appointed to the
staff of the health service at Yale University. Dr.
Mathews is a graduate of Princeton University (1925)
and Harvard Medical School ( 1930) . He was certified
with the American Board of Internal Medicine in 1943.
Before joining the Navy Dr. Mathews was in general
practice in Southport, Connecticut.

Dr. Embree R. Rose, formerly of the department of
student health at Ohio University, reports that he is
enjoying his new position as director of the student
health department at the University of Florida.

The president of Pennsylvania State College an-
nounces that Dr. Herbert R. Glenn of State College,
Pennsylvania, has been appointed to succeed Dr. J. P.
Ritenour as director of the health service in that insti-
tution, to take effect on or about July 1, 1946.

March, 1946

The Present Status of Streptomycin Therapy

ALTHOUGH considerable experimental work is
being conducted on the clinical use of streptomy-
^ cin, only a limited amount of the unintegrated
information is available at the present time. To date,
streptomycin has been tried in human infections resistant
to penicillin, the sulfa drugs, and serum therapy. Ac-
cording to Greey 4 of the University of Toronto, in the
treatment of chronic infections of the urinary tract
streptomycin is effective in destroying such gram-negative
bacteria as Pr. vulgaris, A. cerogenes, E. coli, Ps. cerugi-
nesa, and Eberthella sp. Four hours after commence-
ment of streptomycin therapy ( 1 Gm. of streptomycin
daily in eight divided doses given intramuscularly) , uri-
nary cultures were negative for Pr. vulgaris and, after
eight hours, for coliform organisms. In one case, the
urine became negative for E. coli two hours after treat-
ment.

Though infections of the normal urinary tract were
permanently cleared up, reinfection was likely to occur
in damaged tracts, the catheter serving as the portal of
entry for the new infection. Similar results have been
obtained by the U. S. Army Medical Corps in the suc-
cessful treatment of heretofore resistant urinary tract
infections.

Streptomycin has also proved effective for the treat-
ment of enteric and systemic diseases. In five severe to
moderately severe cases of typhoid, studied by Reimann,''
streptomycin was not administered until late in the de-
velopment of the disease. Nevertheless, the clinical im-
provement of three patients coincided with the period of
streptomycin therapy. In the two unsuccessful cases, the
treatment of one was prematurely discontinued because
of the limited quantity of streptomycin available; failure
in the other has been postulated as a result of inadequate
dosage or the presence in the body of a substance inhibi-
tive to the action of streptomycin. The latter explana-
tion is not very plausible, however, in view of the severity
of the particular case, the long delay in parenteral ad-
ministration, and the fact that no specific streptomycin
inhibitor has yet been demonstrated in the human or
animal body. Although the different strains of typhoid
bacteria varied in their sensitivity to streptomycin, there
was no evidence of increased resistance developed in vivo
during the period of therapy. Although oral administra-
tion alone was inadequate to produce appreciable blood
levels and urine concentrations essential for typhoid con-
trol, it nevertheless rendered the feces free of E. typhosa.

In general it has been suggested that for the treatment
of bacillary infections of the intestinal and urinary tracts
streptomycin be given both orally and parenterally, the
former during the disease as well as in the convalescent
period to prevent reinfection and the carrier state. Oral
administration also has been suggested under certain con-

A section of "Streptomycin — A Review,” by Dr. Selman A.
Waksman and Dr. Albert I. Schatz of Rutgers University,
reprinted with the permission of the authors and the editor
from the Journal of the American Pharmaceutical Association
(Practical Pharmacy Edition), VI: 11 (November), 1945.

ditions as a prophylactic measure against intestinal in-
fections.

In systemic infections, streptomycin has been used by
Reimann 4 to combat Brucella infections. In view of the
variable behavior and chronic nature of the disease and
the limited number of patients thus far treated, no con-
clusion concerning the efficacy of streptomycin against
Brucella infections is justifiable at the present time. The
results, though encouraging, are inconclusive.

In Klebsiella infections, streptomycin has been found
to exert a much more definite action. When treated by
Herrell of the Mayo Clinic (quoted by Heilman1 ),
two patients with Friedlander infections of the respira-
tory tract showed prompt disappearance of Klebsiella
upon the institution of streptomycin therapy. Previously,
the pathogen had been persistently present in the sputum.

Flippin 4 of the University of Pennsylvania observed
that Salmonella as well as E. coli infections lend them-
selves readily to treatment with streptomycin. A patient
with a colony count of 23 million Salmonella in the stool
gave a negative stool after four days’ oral therapy with
1 Gm. streptomycin daily; the number of E. coli were
reduced simultaneously to about 1000; Strep, fcecalis
disappeared and the clostridia were reduced from 75,000
to 8000. Acute brucellosis was successfully treated by
intramuscular administration of streptomycin.

According to Foshay 4 of the University of Cincin-
nati, P. tularensis is one of the most sensitive organisms
in vitro to the bactericidal action of streptomycin. With
only a few micrograms per milliliter, the killing effect
is complete within a matter of seconds, or of minutes
at the most. It is not surprising, therefore, that the par-
enteral administration of relatively low doses of strepto-
mycin has proved remarkably successful in human tula-
remia. Although the mortality of this disease is low,
its morbidity is high; for over 500 untreated cases, the
mean duration was 3.9 months. One patient who began
to receive streptomycin on the eighth day of the disease
was sent home as cured on the seventeenth day. In
another case with perisplenitis and generalized infection
of the peritoneal cavity, the peritoneal fluid was non-
infective on the sixth day after treatment, whereas such
fluid is usually infective for at least nine months. Of
seven cases which had received streptomycin all responded
promptly.

Hinshaw and Feldman at the Mayo Clinic treated
22 tuberculous patients with streptomycin without any
serious toxic effects, even after prolonged administration
of large doses. They concluded, however, that any de-
cision as to the therapeutic efficiency of the antibiotic
must await further study. Hinshaw 4 later observed in
a variety of human infections of M. tuberculosis that
treatment with streptomycin gave some encouraging
results.

Hinshaw and Feldman ! reported the results of pre-
liminary impressions obtained from the study of 34
patients who had tuberculosis and were treated with
streptomycin for a period of nine months. It appeared

The Journal Lancet

that streptomycin exerted a limited suppressive effect,
especially on some of the more unusual types of pul-
monary and extrapulmonary tuberculosis. However,
although the reproduction of Mycobacterium tuberculosis
appeared to be temporarily inhibited by the treatment,
no convincing evidence was obtained as to a rapidly
effective bactericidal action.

It must be emphasized that the information available
is much too limited in scope for any evaluation at the
present time. The pathological nature of tuberculosis
and the clinical characteristics are such that prolonged
treatment and studies of many cases are absolutely pre-
requisites for any serious consideration of the efficacy of
streptomycin in the treatment of this disease. To date,
sufficient information has not been accumulated.

Limited results have been obtained for meningitis from
the treatment of a dozen or so cases. According to Mar-
garet Smith 4 of Sydenham Hospital and Birmingham 4
of the Johns Hopkins Hospital, some patients recovered
from influenzal meningitis following administration of
streptomycin alone. When insufficient doses of the drug
were used, there was a definite development of drug-
fastness of the organism. It was believed that optimal
treatment may finally comprise streptomycin coupled
with sulfadiazine or with serum therapy, or both.

Sterilization of spinal fluid and blood was accom-
plished, in a case of a four-year-old boy, in nine hours.
The treatment consisted of injections of 200 mg. strep-
tomycin every two hours for five days. It was recom-
mended that intrathecal administration of streptomycin
should always accompany intramuscular therapy.

One case of Salmonella meningitis was treated success-
fully with streptomycin, although it was suggested that

the exact role of the antibiotic in this one patient should
be considered as inconclusive. No cases of E. coli menin-
gitis in newborns have yet been treated with streptomy-
cin. Since such infections, which are not rare, are gen-
erally nonresponsive to the sulfonamides and are almost
always fatal, streptomycin may prove effective. In the
few patients with tuberculous meningitis, the administra-
tion of streptomycin did not appear to help very much.

Howes 4 of Columbia University, studying the treat-
ment of wound infections with streptomycin, observed
that 100 micrograms per ml. did not affect the growth
of tissue culture at all, whereas 200 micrograms were
only moderately inhibitory. At least 14 wounds were
sutured with a mixture of 200 units of streptomycin and
5 per cent marfanil, without any infections of the
wounds and no untoward reactions. The stability of
streptomycin solutions, in contrast with those of peni-
cillin, was believed to be of special significance.

Adequate surgery, followed by streptomycin treatment,
will undoubtedly prove highly effective, as suggested by
Hirshfeld 4 and by other clinicians.

References

1. Heilman, F. R.: Streptomycin in the Treatment of Ex-
perimental Infections with Microorganisms of the Friedlander
Group (Klebsiella). Proc. Staff Meetings Mayo Clinic, 20,
33-39, 1945.

2. Hinshaw, H C., and Feldman, W. H.: Observations on
Chemotherapy of Clinical and Experimental Tuberculosis. Med.
Clin. North America, Mayo Clinic Number, 918-22 (July),
1945.

3. Hinshaw, H. C., and Feldman, W. H.: Streptomycin in

Treatment of Clinical Tuberculosis: A Preliminary Report.

Proc. Staff Meetings Mayo Clinic, 20, 313—18, 1945.

4. Personal communication.

5. Reiman, H A., Elias, W. F., and Price, A. H.: Strep-
tomycin for Typhoid. J.A.M.A., 128, 175-80, 1945.

In a congressional committee hearing in Washington dealing with wartime health and
education, Dr. A. N. Richards, chairman of the committee on medical research, by request
listed the following as among the more conspicuous examples of the results wholly or in large
part, of research undertaken with government subsidy by his and associated committees:
1) the acquisition in civilian hospitals and laboratories of sufficient knowledge of the thera-
peutic power of penicillin, by which the medical divisions of the Army and Navy became
convinced of its usefulness, and which provided impetus for the production program which
has made this remarkable drug available in huge quantities, one of the most important; 2)
the work sponsored and financed by Office of Scientific Research and Development in the
Department of Agriculture, which taught the producers of penicillin to increase the yield a
hundredfold over that which the British discoverers of penicillin had been able to do, within
a few months after we knew about it in this country; 3) the improvements in insect repellents
and insecticides, important in guarding troops against infections, which could not have been
made without the equivalent of the aid which Office of Scientific Research and Development
has given; 4) the program for study of human blood plasma constituents which has led to
use by the armed services of human serum albumin as a blood substitute, of immune glob-
ulins to combat infections, of fibrin foams to stop bleeding, which could not have succeeded
without the equivalent of the support given by Office of Scientific Research and Develop-
ment; 5) the present adopted regimes of atabrine usage against malaria; 6) the determina-
tion of the relative usefulness of sulfonamide drugs in the treatment of wounds and burns;
7) the indoctrination programs of our airmen, as well as the devices which enable them to
endure the rigors of high altitudes without disastrous loss of fighting capacity.

March, 1946

The Sprue Syndrome

Louis Pelner, M.D.

Brooklyn, New York

THE sprue syndrome is here considered to be a
series of disorders all of which have steatorrhea,
and which are characterized by the passage of
large, pale, fatty, and frothy stools, distention of the ab-
domen, diarrhea, soreness of the tongue and mouth, pro-
gressive emaciation, defective calcium metabolism, and
anemia. All of these symptoms have a tendency to re-
mission and relapse. The most characteristic part of this
syndrome is the steatorrhea. This disorder can occur in
various forms which are very similar. These types are
celiac disease in infants and small children; idiopathic
steatorrhea, which occurs at a later date than the child-
hood disease; nontropical sprue, which consists of the
sprue syndrome in persons who have never been in the
tropics, and lastly, tropical sprue.

Since steatorrhea or fatty stools is one of the charac-
teristics of sprue, it is worth while to list other diseases
in which this symptom is found. Steatorrhea can be
caused by the following factors:

1. Defective digestion of fat. In this condition, the
bile or pancreatic lipase may not reach the duodenum be-
cause of the obstruction of the bile or pancreatic ducts,
or of a chronic pancreatitis. Another possibility may be
the inactivation of the enzymes because of an improper
pH of the duodenal contents. This can be present in a
poorly functioning gastrojejunostomy or a gastrojejuno-
colic fistula.

2. Poor absorption of the split and emulsified fat.
This is characteristic of the sprue syndrome. Bile and
pancreatic lipase are present and are found in a suitable
pH environment, but the digested fat is not absorbed
through the villi of the small intestine. The essential
factor causing this lack of absorption is not known, but
a theoretical discussion of this will be given later.

3. The fat may be absorbed through the villi, but for
some reason cannot pass through the lacteals, if these are
blocked by large mesenteric glands. This can happen in
tuberculosis of the mesenteric glands, Hodgkin’s disease,
carcinoma, or amyloid deposits in the glands.

The sprue syndrome, as explained above, is due to in-
adequate absorption of properly digested fats. The cause
of this lack of absorption is not known. This condition
may also occur after the operative excision or disease of
a large part of the small intestine. Some consider the
sprue syndrome to be caused by the lack of a factor,
such as one of the B-complex vitamins, which causes a
lack of essential substances necessary for the proper activ-
ity of the blood and the gastrointestinal tract. This re-
sults in the failure to absorb fat, and less so carbohy-
drates and proteins. Since the absorption of calcium is
closely associated with the absorption of fat, its absorp-
tion also suffers. Likewise, fat-soluble vitamins are poorly
absorbed. Thus the skeletal deformities, edema, tetany,
and anemia can be explained.

The symptoms of the sprue syndrome vary somewhat
in each of the diseases mentioned as comprising the syn-
drome. It may be that all are different degrees of the
same disease. In celiac disease, the complaint may be
merely a difficulty in digesting milk, but later this condi-
tion tends to be quite severe, causing muscular weakness
and slow mental and bodily development. In the adult
condition, recurrent attacks of diarrhea, especially in the
morning, a flatulent dyspepsia with distended abdomen,
loss of weight, sore tongue and sore mouth, are present.
In the early stage, diarrhea, which, is the one characteristic
of the syndrome, may appear like any other simple diar-
rhea. Very soon the typical mushy, pale stool with gas
bubbles supervenes. The characteristic of this stool is
the excess fat and the increased bulk of the stool. This
fatty stool differs markedly from that found in pancre-
atic steatorrhea, in which the oil separates out, and ap-
pears to look like butter. A table comparing both stools
is given here.

The abdominal wall is markedly distended so that
often a diagnosis of tuberculous peritonitis or Hirsch-
sprung’s disease has to be entertained.

X-ray examination of a typical case of the sprue syn-
drome shows a delayed motility of the barium meal.
There is an alteration of the mucosal relief of the jeju-
num. The contour of the bowel wall is smooth. The
valvulae conniventes appear all but gone. The small in-
testine appears like a group of frankfurters hanging to-
gether. This analogy illustrates the segmentation, pud-
dling, and obliteration of the mucosal relief. There is
also a dilatation of the colon with the loss of the haustral
markings. The lack of absorption of fat is considered to
be the sole cause of these X-ray findings. However, it is
not altogether unlikely that the substance responsible for
the lack of absorption causes this picture as well. This
factor appears to be found in crude liver extract and the
vitamin B-complex group, because these changes can be
reversed by use of these substances. Recently similar
changes of the small intestine have been found in vita-
min B-complex deficiency and, indeed, some authorities
use these X-ray findings as a mode of diagnosis of this
condition.

Other prominent findings in the sprue syndrome are
soreness of the tongue, which is usually clean, devoid of
fur, but sometimes red and swollen. The loss of weight
is very striking as compared with the large protuberant
abdomen. Occasionally a hemorrhagic rash is found
which will clear up with vitamin C administration. The
anemia of sprue is also one of the characteristic findings.
This may be either a hypochromic or hyperchromic
anemia. Strangely enough, in a hypochromic anemia the
patients have a waxy pallor, whereas with the hyper-
chromic, megalocytic anemia, these patients have a lemon
yellow tint to their skin. Tetany is a frequent occurrence
in this condition owing to the loss of calcium in the stool.
In addition vitamin D is also lost in the stool because of

its fat solubility. Pains in the bones and joints are fre-
quently found and are due to the lack of absorption of
both calcium and vitamin D. This results in a stunting
of growth and a deformity of the skeleton.

The diagnosis of sprue is not made sufficiently often
in this country, probably because the secondary manifes-
tations that it includes are taken to be the disease proper.
In order to prevent incorrect diagnosis, we must review
every case of pernicious anemia, idiopathic diarrhea, and
every case of severe vitamin deficiency.

Differential Diagnosis

The differential diagnosis of this condition must in-
clude pancreatic steatorrhea, which has so many distin-
guishing factors that it should not entail much difficulty.
A table listing the differences in this condition is includ-
ed in this article. The fat in pancreatic steatorrhea is
undigested, oily fat, which separates, producing the so-
called "butter stool.” Another very important character-
istic differentiating this condition from pancreatic dis-
ease, is that sprue has a flat glucose-tolerance curve. The
test in these cases shows a low fasting blood sugar, and
after the ingestion of glucose shows very little rise. Why
this should be true is debatable, since this disease is pri-
marily a disturbance of fat metabolism. However, if
banana flour is given instead of glucose, the usual rise in
the blood sugar occurs. This fact has been made use of
in treatment.

As mentioned before, sprue may have a macrocytic,
hyperchromic anemia, which resembles in all character-
istics the blood smear of pernicious anemia. However,
in sprue the patients are emaciated, while in pernicious
anemia the patients appear well fed. In pernicious anemia
the steatorrhea is not found. In sprue, the presence of
indirect van den Bergh reaction is rare, but in pernicious
anemia it is quite regularly found. In sprue only 50 per
cent of the cases have an absent hydrochloric acid con-
tent of the stomach, whereas in pernicious anemia this
finding is exceedingly frequent. With adequate therapy
in sprue, this condition remits, whereas in true pernicious
anemia the achlorhydria is constant.

The defects of calcium metabolism are often consid-
ered to be isolated diseases, but sometimes may be a part
of the sprue syndrome. The presence of steatorrhea facil-
itates the diagnosis. In infants and small children the dif-
ferential diagnosis from Hirschsprung’s disease may easi-
ly be made by analysis of the stool to exclude steatorrhea.

The treatment of any of the diseases comprising the
sprue syndrome is largely dietary. The only recent im-
provement on this treatment is the use of parenteral liver
extract. Many authors have stated that this substance
exerts a specific effect on the absorptive power of the
small intestine. Two cubic centimeters of the crude ex-
tract can be given intramuscularly three times a week.
The diet should be high in protein, moderately low in
carbohydrates, and extremely low in fat, and should con-
tain adequate amount of vitamins and minerals. An illus-
trative diet list is included in this article. Careful atten-
tion should be given to the type of carbohydrate, which
early in the disease should consist only of bananas and
strawberries. Many of the symptoms of sprue in the in-
dividual case will require individual vitamin therapy; thus
glossitis and stomatitis will usually yield to about 300 mil-

The Journal Lancet

DIFFERENTIAL DIAGNOSIS BETWEEN PANCREATIC
STEATORRHEA AND IDIOPATHIC STEATORRHEA

Pancreatic

Steatorrhea

Idiopathic

Steatorrhea

Appearance of stool

Butter stool — oil
separates out,
especially if cold.
Gray color

Light, pale, frothy,
voluminous stool

Total fat content (dry wt.)
(Normal 15 to 25%)

Approximately

50%

Approximately

50%

Pet. of fat excreted as
normal fat

(Normal less than 50% )

More than 50%

Normal

Pet. of fat excreted as fatty
acid or calcium soaps

Less than 50%

More than 50%

Microscopic — Sudan III

Neutral fat present Fatty acid present

Associated creatorrhea

Present

Absent

Sugar tolerance curve

Normal. May be
diabetic or
hypoglycemic

Usually flat

Glycosuria

May be present

Absent

Serum phosphatase

Normal

May be elevated

Plasma protein

Normal

Usually low

Anemia

None

Usual

Nitrogen content in stool

Increased above
3 grams of
dried weight

May be decreased
or normal

Vitamin deficiency

Occasional

Usual

Basal metabolic rate

Normal

High

Duodenal enzymes

Decreased

Normal

Urinary diastase

High

Normal

(Modified from Bockus s Gastroenterology . The figures given
are approximations, and differ slightly with each authority.)
(Courtesy of W. B. Saunders.)

ligrams of nicotinic acid and 5 milligrams of riboflavin
daily. A hemorrhagic rash will require use of about 300
milligrams of vitamin C daily.

When severe weakness is present, suprarenal cortical
extract is useful. A potent preparation of this substance
can be given in doses of 2 cc. every other day. The
suprarenal cortex hormone is said to be involved in the
absorption and phosphorylation of fats, and also one of
these hormones, corticosterone, exerts an influence on car-
bohydrate metabolism. The natural hormone is probably
better than the synthetic one, because it contains more of
the needed factors. The anemia should be treated with
adequate doses of liver extract just as in pernicious ane-
mia. In addition, iron in the form of ferrous sulphate
should be taken in the form of dicalcium phosphate with
viosterol. Vitamin B complex should preferably be given
either in the form of brewer’s yeast in adequate doses
(12 to 18 tablets daily), or the natural vitamin B com-
plex syrup or capsules, since some of the unknown ele-
ments of this complex may be an important factor in in-
creasing the absorption of substances from the intestinal
tract.

Suggested Reading

Paine, J. R.: Diagnosis of Intestinal Obstruction, American J.

Surg. 56:87 ( 1942).

DIET FOR SPRUE AND IDIOPATHIC STEATORRHEA
Breakfast

Melba toast. 1 quarter of a glass of orange juice. 2 ripe ba-
nanas. 1 serving of boiled liver. Coffee or tea.

Dinner

1 quarter of a glass of orange juice. 2 ripe bananas. Slice of
Melba toast lightly buttered. 1 egg. 1 serving of a very lean steak.

Supper

Orange juice, 1 quarter of a glass. 2 bananas. Slice of Melba
toast lightly buttered. 1 serving of lean broiled steak.

Add the following foods, in the order enumerated, after a
period of one or two weeks:

Honey; bland cooked fruit; vegetable puree consisting of spin-
ach, lettuce, celery, eggplant and young string beans; custard,
sweetened with glucose; baked potato; cottage cheese without milk
or cream; fish and meats, besides those listed above; low residue
vegetables (carrots, beets, asparagus tips, squash, string beans, spin-
ach: fresh strawberries, pears, baked apple, strained apple sauce,
cooked pears, peaches and apricots.

Serves the /\ Medical Profession of

MINNESOTA, NORTH DAKOTA, ' ' SOUTH DAKOTA and MONTANA

North Dakota State Medical Assn.

Dr. James F. Hanna, Pres.

Dr. A. E. Spear, Pres.-Elect
Dr. L. W. Larson, Secy.

Dr. W. W. Wood, Treas.

North Dakota Society of
Obstetrics and Gynecology
Dr. E. H. Boerth, Pres.

Dr. Paul Freise, Vice Pres.

Dr. G. Wilson Hunter, Secy. -Treas.

Minneapolis Academy of Medicine
Dr. Karl W. Anderson, President
Dr. Russell W. Morse, Vice Pres.

Dr. J. C. Miller, Secretary

Dr. Ragnvald S. Ylvisaker, Treasurer

Dr. Henry E. Hoffert, Recorder

ADVISORY COUNCIL

South Dakota State Medical Assn.
Dr. William Duncan, Pres.

Dr. F. S. Howe, Pres.-Elect
Dr. H. R. Brown, Vice Pres.

Dr. Roland G. Mayer, Secy .-Treas.

South Dakota Public Health Assn.
Dr. J. M. Butler, Pres.

Dr. C. E. Sherwood, Vice Pres.

Dr. Gilbert Cottam, Secy.-T reas.

Sioux Valley Medical Assn.

Dr. D. S. Baughman, Pres.

Dr. Will Donahoe, Vice Pres.

Dr. R. H. McBride, Secy.

Dr. Frank Winkler, Treas.

BOARD OF EDITORS

Dr. J. A. Myers, Chairman

Montana State Medical Assn.

Dr. S. A. Cooney, Pres.

Dr. M. A. Shillington, Pres.-Elect
Dr. R. F. Peterson, Secy .-Treas.

Northwestern Pediatric Society
Dr. G. B. Logan, Pres.

Dr. Geo. Kimmel, Vice Pres.

Dr. Northrop Beach, Secy .-Treas.

Great Northern Railway Surgeons' Assn
Dr. W. W. Taylor. Pres.

Dr. R. C. Webb, Secy .-Treas.

American Student Health Assn.

Dr. Ralph I. Canuteson, Pres.

Dr. Glenadine Snow, Vice Pres.

Dr. G. T. Blydenburgh, Secy. -Treas.

Dr J . O. Arnson
Dr. D. S. Baughman
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. A. R. Foss

Dr. James M. Hayes
Dr. A. E. Hedback
Dr E. D. Hitchcock
Dr. R. E. J ernstrom
Dr. A. Karsted
Dr. L. W. Larson
Dr. W. H. Long
Dr. O I Mabee
Dr. J. C. McKinley

Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C H. Nelson
Dr. N. J . Nessa
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K A. Phelps
Dr. C. E. Sherwood

Dr. M. A. Shillington
Dr. J C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. I . H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. S. E. Sweitzer

Dr. W. H. Thompson
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. O. H. Wangensteen
Dr. S Marx White
Dr. H. M. N Wynne
Dr. Thomas Ziskin,
Secretary

LANCET PUBLISHING CO., Publishers, 84 South Tenth Street, Minneapolis 2, Minnesota

Minneapolis, Minnesota, March, 1946

PSYCHOTHERAPY STRIDES FORWARD

Dr. Charles H. Mayo, speaking at a banquet of The
Interstate Post-Graduate Assembly in Detroit about ten
years ago, deplored the lack of progress in the treatment
of mental diseases in the past, but predicted that the
greatest advances in scientific medicine during the next
thirty years would be along the lines of psychotherapy.
His was a prophetic soul: the accuracy of his prediction
is now being realized in both war and peacetime pro-
cedures.

The most spectacular example of this progress, that
which first comes to the mind of every student of the
subject, is the wonderful results achieved by prompt
emergency treatment of acute psychosis on the battlefield
during World War II. In former frays, because phys-
ical mutilation is more apparent, such cases received first
attention, to the disadvantage of those whose minds
were affected. Mental cases were for the most part
dazed, quiet, and uncomplaining, and thus lacked the

urgent appeal. Perhaps also it was because of a feeling
that little could be done for mental casualties, beyond
time and rest. At any rate they were neglected, not
intentionally, but because of failure to appreciate the
need, the very great need, of first aid for such cases.

In civilian life, too, psychiatric practice has undergone
a great change in the past decade. Today’s successful
sanitarium does more than merely supply isolation from
the irritations of a highly geared, competitive world. It
furnishes specific therapies, most of which have been
developed and perfected during the past ten years. We
have in mind insulin coma, metrazol convulsive therapy,
and electroshock treatments. Surgery has contributed
the operation of prefrontal lobotomy. Work in mental
hospitals has now become more interesting because there
is an added incentive to apply these promising modern
technics to patients, to the end that they may be cured
and discharged in the shortest possible time.

A. E. H.

The Journal Lancet

BREAD

An article* with this down-to-earth title in our ven-
erable name-giver, the British Lancet, is of timely in-
terest in view of the recent order for higher extraction
bread and the resulting beige-colored "white” bread in
the United States.

After a thoroughgoing consideration of the structure
and composition of wheat grain, the bakers and the pub-
lic, the millers’ point of view, the nutritional value of
wheat and wheat flours, and the effect of the war, Pro-
fessor McCance voices his own recommendations. "If
the health of the people really is the first consideration
in our bread policy,” he writes, "the cheapest, safest, and
easiest way to maintain this is to keep up the extraction-
rate of the flour used for bread-making. Speaking per-
sonally— i.e., nutritionally — I would like to see 85%
flour and the "National” loaf reintroduced. ... If this
were done as a long-term policy, milling techniques would
be improved and adapted in conformity, and this would
lead to a betterment in the 85% flours. Calcium should
be added to neutralise the bad effects of phytic acid.

"I recognise that there are difficulties about 85%
flour. One is its keeping qualities, which are not so good
as those of 70%' flour. . . . Now there are, I believe,
two aspects of this. One is that the 85% flour goes 'off’
on keeping because the fat in the germ becomes rancid.
. . . Another is that the baked loaves go mouldy quicker
than loaves made from 70% flour. This may be a mat-
ter of the moisture content, but it may well be a sign
of nutritional quality, for these moulds are very discrim-
inating little creatures and will only grow on the very
best media. They much prefer, therefore, an 85% to
an 80% or 70% loaf.

"The millers will always be in a difficulty with long-
extraction flours, so long as the public has a free choice
of loaf and remains more interested in football pools
than positive health; but although I hate bureaucratic
control I do not feel that these difficulties are insupera-
ble. A good test for the extraction-rate of flour would
be a help. Much could be done by frankly and honestly
putting the case for its own health before the public.
If we revert to a flour of 70% extraction, it will be
much more difficult and much more expensive on purses
and imports to ensure that Mr. Tom, Mrs. Dick, and
Master Harry get their supplies of nutritional minutiae,
and I personally would not care to undertake to do it.”

*Vol. CCL, No. 6386, January 19, 1946. By R. A. Mc-
Cance, M.D., Ph D. Camb., F.R.C.P., Professor of Experi-
mental Medicine, University of Cambridge.

Tuberculosis can be controlled and the fight against
it must be continued until it is controlled. The Ameri-
can people cannot be complacent about a disease which
exacts such a tragic and needless toll of lives. Today,
in particular, it is inexcusable to permit disease to under-
mine the strength of our people when all their energy
is needed in the building of a better world. — Harry S.
Truman.

ANNOUNCEMENTS
Graduate Course in Diseases of the Chest

The American College of Chest Physicians, of which
Dr. Jay Arthur Myers, Minneapolis, is president, an-
nounces that a postgraduate course in diseases of the
chest will be given at Michael Reese Hospital, Chicago,
during the week April 1-6, inclusive, under the auspices
of the Illinois Chapter. Doctors may elect to follow the
formal course, with practical instruction in the fields of
thoracic surgery, bronchoscopy, pneumothorax, bronchog-
raphy, and other methods and technics in the diagnosis
and treatment of pulmonary disease.

Further information may be secured from the offices
of the College, 500 North Dearborn Street, Chicago 10,
Illinois.

Annual Meeting, American Association for
the Study of Goiter

The Association announces that its first annual meet-
ing since 1941 will be held at the Drake Hotel, Chi-
cago, June 20-22, inclusive. The Program Committee
announces that special features, such as a paper on radio-
active isotopes in relation to the investigation and treat-
ment of thyroid disease, have been planned. Those who
desire to read papers are requested to send the titles at
once to the program chairman, Dr. S. F. Haines, Mayo
Clinic, Rochester, Minnesota.

Preceptorships, American Board of
Ophthalmology

The Secretary of the Board, Dr. S. Judd Beach,
sends the following notice concerning preceptorships.

In regard to the substitution of a preceptorship for
residency in an ophthalmic hospital, the American Board
of Ophthalmology has always accepted such training in
favorable cases. During the present overcrowding of
facilities, the Board expects to take a liberal attitude
regarding the requirements for training.

It should, however, be pointed out that neither a resi-
dency nor a preceptorship suffices in itself to meet the
requirements of the Board. Each case will still be judged
on its merits in determining fitness for examination.

In entering upon a preceptorship certain conditions
should be kept in mind. First the student will profit
most after a sound course in the basic sciences of phys-
iology of the eye and of vision, optics, pathology, bac-
teriology, chemistry, pharmacology, the relation of the
eye to general disease, anatomy, embryology, and neur-
ology. This is essential for a residency, more so for a
preceptorship. While men have been accepted from pre-
ceptors who are not diplomates of the Board, it is ob-
vious that the Board has more information about those
teachers who have passed its examinations.

Any preceptor should understand that he is assuming
a responsibility in taking a student and is not merely
obtaining help in the drudgery of his office. He should
be willing to give time to clinical training and the use
of apparatus, slit-lamp, ophthalmoscope, tonometer, and
to directing the student’s practice in surgery on animal

March, 1946

eyes, assisting in operations, and ultimately in the per-
formance of them.

To cover the same amount of ground will take much
longer in a preceptorship than in a residency, and stu-
dents should accept opportunities to take hospital posi-
tions cf all sorts as they become available.

Annual Convention and Postwar Conference,
American Hospital Association

The Association will hold its 48th annual convention
and postwar conference in Philadelphia during the week
starting Monday, September 30. The Bellevue-Stratford
and Benjamin Franklin hotels will provide accommoda-
tions. A housing bureau will be conducted in the Asso-
ciation’s Chicago headquarters, 18 East Division Street,
to handle requests for living quarters. The Philadelphia
Commercial Museum, Exhibition, and Convention Hall
has been booked for meetings and exhibits.

Annual Meeting, American Public Health
Association

The Executive Board of the American Public Health
Association announces that its 74th annual meeting will
be held in Cleveland the week of November 11. This
will be the first full-scale convention of the Association
since 1942. An attendance of 4000 is anticipated. Dr.
Harold J. Knapp, Cleveland’s Health Commissioner, is
Chairman of the Local Committee.

The 1947 Norton Medical Award

W. W. Norton & Company, publishers, announce that
they are again inviting the submission of manuscripts
to be considered for the Norton Medical Award of
$3500, offered to encourage the writing of books on
medicine and the medical profession for the layman.

The first such award was made to The Doctor’s Job,
by Dr. Carl Binger, published in the spring of 1945.
Announcement will be made shortly of the winning book
for 1946. Closing date for submission of manuscripts
this year is November 1, 1946. Particulars relating to
requirements and terms may be obtained from the pub-
lishers, 70 Fifth Avenue, New York 11, N. Y.

New Medical Journals

Two new medical journals, the Quarterly Review of
Psychiatry and Neurology and the Quarterly Review of
Urology, will be issued soon by the Washington Insti-
tute of Medicine.

Dr. Winfred Overholser, Professor of Psychiatry,
George Washington University School of Medicine,
and Superintendent of St. Elizabeth’s Hospital, is
Editor-in-Chief of the first-named review. It will be
published in January, April, July, and October. The
annual subscription rate is $9.00.

The Quarterly Review of Urology, issued in March,
June, September, and December, also at $9.00 a year,
has Dr. Hugh J. Jewett of Johns Hopkins University
as Editor-in-Chief. Included on the Editorial Board of
ten are Dr. William F. Braasch of the Mayo Clinic and
Dr. Reed M. Nesbitt of the University of Michigan.

. . . fUEET OUR COEITRIBUTORS . . .

Dr. Irving Howard Mauss, S.A. Surgeon (R)
attached to the U. S. Public Health Service with the
U. S. Marine Hospital, Memphis, Tennessee, was
director of the Pennington County Health Department,
Rapid City, South Dakota, at the time the paper pub-
lished in this issue was written. Dr. Mauss will soon
be on terminal leave and will return to his home in
Brooklyn. Dr. Mauss is a graduate of the Royal College
of Physicians and Surgeons of Glasgow, Scotland (1940) ,
and interned at Sinai Hospital (one year in pathology)
and Baltimore (one year in medicine) . He is a member
of the Black Hills (Ninth) District Medical Society
of South Dakota, the American Public Health Associa-
tion, the South Dakota Public Health Association, and
the American-Soviet Medical Society.

Dr. William E. Olson of Fort Meade, South Da-
kota, has practised his specialty, psychiatry, there since
April 1945. He is a graduate of the University of
Nebraska College of Medicine (1930).

Dr. Louis Pelner of Brooklyn is associate physician
of the Greenpoint Hospital, assistant attending physician
of the Brooklyn Cancer Hospital, and adjunct attending
physician of Beth Moses Hospital. He is a graduate of
the New York University College of Medicine, with
graduate work at the Post Graduate Hospital, the New
York Medical College, and the Lahey Clinic. He is a
member of the Kings County Medical Society, the Amer-
ican College of Allergists, the American Federation for
Clinical Research, and the New York Diabetic Society.

ORIGIN OF THE NAME "CESAREAN”

Palmer Findley, in his Priests of Lucina, says that
"so far as the records show the cesarean operation was
not performed on the living woman in the time of Julius
Caesar. This fact should effectually dispose of the pop-
ular belief that the name of the operation was derived
from the alleged manner of birth of Julius Caesar. It
is the consensus that the name was derived from the lex
regia, in which it was ordered that an abdominal section
must be performed on all dead and dying women when
in the advanced state of pregnancy. Later, the lex regia
became known as the lex cesana and from this law the
name cesarean was derived.”

The earliest authenticated cesarean on a living woman
was performed in 1500 by Jacob Nufer, a butcher who
specialized in the gelding of sows. In Bauhin’s account
of the event ( Fr . Rousset, Basle, 1588) at Sigerhausen,
it is recorded that he "locked the door, offered prayer,
placed his wife on the table, and cut her abdomen open.
The cut was so skillfully done that the child was re-
moved at once without injury. . . . Later his wife gave
birth to twins, and gave birth four times more. The
child which was cut from her body lived 77 years.”

The Julius Caesar legend does not hold up in the
light of the historic facts. — Medical Times, 74: 2, 45
(February), 1946.

The Journal Lancet

BmIc lUviews

Hypnoanalysis, by Lewis R. Wolberg, M.D. New York:

Grune and Stratton, 1945. Pp. 342. #4.00.

Every practising physician is frequently confronted with the
problem of what to do for the patient whose complaints arise
out of a disturbed emotional or mental state.

Although efforts to do something helpful are extremely varied
in practice, they depend for their success on the inclusion of
the fundamental techniques of psychotherapy, which are sug-
gestion, persuasion, and analysis. Dr. Wolberg has here de-
voted himself to an exposition of the technique and theory of
hypnoanalysis, which utilizes hypnotic suggestion in aiding the
analysis of the personality disturbance.

Psychiatrists have long recognized that psychoanalysis in its
orthodox form, as discovered and developed by Freud and his
co-workers, has limited usefulness as a therapeutic method,
since it is time consuming for the therapist, expensive to the
patient, and subject to certain unavoidable failures arising out
of the uncontrollable resistance of the patient to abandoning
his defenses or neurotic goals.

Orthodox psychoanalytic therapy is still in use today in spite
of these practical drawbacks, because it is the only therapy
effective in certain patients whose lives are hideously blighted
by neurotic distortions in personality. Efforts to find techniques
which are less time consuming and more universally effective
have been pursued by the psychoanalytic group for a quarter
of a century, and this book by Dr. Wolberg represents one
of the most likely modifications which are in the experimental
stage today.

Dr. Wolberg begins his book with a detailed account, com-
prising 132 pages of the analysis of a state hospital patient
who appeared to be a deteriorated schizophrenic. Hypnosis was
used extensively throughout the analysis to uncover unconscious
material, break through the patient’s resistance, and promote
re-education along lines of mental health. After four months
of intensive treatment the patient was completely recovered and
remained so after two years outside the hospital. The move-
ment of the patient during the treatment is such as to make
extremely unlikely the theory that a spontaneous recovery (such
as is not infrequently seen in untreated schizophrenics) occurred.

The last six chapters of the book are devoted to the prac-
tice and theory of hypnoanalysis, apparently largely as evolved
in Dr. Wolberg’s own experience. Case material is drawn on
frequently to illustrate points in technique.

The first half of this book might well be of interest to any
physician who cares to familiarize himself with the revelations
patients make in a psychoanalytic relationship. The material is
given in sufficient detail (much of it is quoted verbatim) to pro-
vide an opportunity to form a judgment as to the validity of
the basic data upon which psychoanalytic theory is founded.
The chapters on technique and theory are, however, of value
only to psychoanalytically trained psychiatrists who may wish
to repeat Dr. Wolberg’s experiment in a case or two of their
own. — Alan Challman, M.D.

Dysentery, Colitis and Enteritis, by Joseph Felsen, B.A.,
M.D., Director of Medical Research, Bronx Hospital, New
York; Director of International and Pan-American Dysen-
tery Registry. Philadelphia and London: W. B. Saunders
Company, 1945. Pp. 618, illustrated; 9 color plates. #6.00.

Dr. Felsen has now completely documented his oft-repeated
thesis that chronic ulcerative colitis in most instances stems from
bacillary dysentery. Not only the condition commonly known
as idiopathic or nonspecific ulcerative colitis, but also ileitis and
enteritis and colitis, variously designated, are considered to be
sequelae of bacillary dysentery. This concept indubitably simpli-
fies considerations of the etiology of several inflammatory dis-
orders of the large and small bowel, directs attention to the
epidemiological relationship of several apparently unrelated con-

ditions, and emphasizes prevention. But for purposes of man-
agement and treatment of particular cases a somewhat more
eclectic classification would seem to offer more profitable oppor-
tunities.

Perhaps no one has done more or better bacteriological or
serological investigation of colitis than Dr. Felsen. Concerning
the disorder as a general, systemic disease his work has yielded
much valuable information, which is here presented in complete
detail. Even gastroenterologists and general practitioners who
have reservations concerning the validity of the hypothesis
should study these data thoughtfully with the purpose of apply-
ing whatever is pertinent to a vexatious problem common in all
practice.

Classic Descriptions of Disease, by Ralph H. Major. 3d
ed., revised and enlarged. Springfield, Illinois: Charles C
Thomas, 1945. Pp. 679. #6.50.

With three editions off the press, Dr. Major’s compilation of
classic descriptions is itself becoming a classic. The book is a
history of medicine unusual in its departure from the customary
procedure of grouping all papers in chronological order. The
chapters are by subject rather than by eras. This simple device
enhances the value of the work to most practitioners, whose in-
terest lies in a particular subject rather than in a special period.

Old English writings are given in the original. French, Ger-
man, Latin, and Greek works are translated. As is stated in the
preface, "Mistakes [in translating] have probably crept in, since
in many places it is difficult to be sure just what thought some
Italian, Frenchman, or Spaniard writing in medieval Latin was
trying to express, and at times the translator almost wonders if
the author himself knew.”

Articles selected for quotation have been largely limited to
inaccessible and unavailable journals and books. — R. B.

Trauma in Internal Diseases, with Consideration of Ex-
perimental Pathology and Medicolegal Aspects, by

Rudolf A. Stern. New York: Grune & Stratton, 1945.

Pp. 575.

Health and accident insurance policies, accidental death bene-
fits, workmen’s compensation laws, and other types of insur-
ance bearing on accidents have given the subject of trauma and
disease an importance beyond medical considerations. Here is
a field of medicine where etiology often is decided in a legal
rather than a pathologic amphitheater. Dr. Stern takes up the
subject of trauma from the point of view of the expert medical
witness. He presents case histories profusely, the denouement
being the award or denial of compensation. His book will
serve as a handy reference for physicians called to testify in
cases of trauma and disease. Physicians unaccustomed to the
ordeal of legal examination and cross examination can profit
much from the introduction, which is concerned with general
facts concerning the importance of trauma in the etiology of
internal diseases.

Suggested School Health Policies: A Charter for School
Health. 2d ed., revised by the National Committee on
School Health Policies of the National Conference for Co-
operation in Health Education. New York and Minneapolis:
Health Education Council, 10 Downing St., New York 17,
1945. Pp. 46. 25 cents.

This guide integrates the points of view of many professional
groups on the contributions that school programs can make to
the health of children and communities. It points out that
healthier school living can be acquired by raising the standards
of inspection for safety and sanitation, improving the quality of
health instruction, instituting wider programs of health coun-
seling, and enforcing more intelligent precautions in physical
education.

The school health council recommended would coordinate the
efforts of teachers, parents, and physicians in planning the
health policies of the school and determining and implementing
better health procedures.

March, 1946

The Dietary of Health and Disease, by Gertrude I.
Thomas. 4th ed., revised. Philadelphia: Lea & Febiger,
1945. Pp. 308, illustrated. $3.50.

In the fourth edition of this practical and comprehensive
book the author, Assistant Professor of Dietetics at the Uni-
versity of Minnesota, has incorporated recent findings from
nutrition research and psychodietetics. Particularly valuable to
the physician who must direct the dietaries of his patients are
the chapters concerning the choice and preparation of food for
patients suffering from various diseases.

Brazil: Orchid of the Tropics, by Mulford B. and Racine
S. Foster. Lancaster, Pennsylvania: The Jacques Cattell
Press, 1945. Pp. xi -p 314, illustrated. $3.00.

So delightfully do the naturalist-explorers, Mulford and Ra-
cine Foster, relate the story of their months of search and dis-
covery in Brazil that one is transported from one’s fireside to
join this inspired and intrepid pair in their hunt for rare and
new orchids, bromeliads, and cacti. The difficulties and dangers
encountered during their 12,000-mile expedition from Bahia to
Parana and through the interior of Matto Grosso to the Bo-
livian border make interesting reading.

Through mountainous rain forests, virgin jungle, deep
swamps, and narrow rocky gorges lush with tropical vegetation
they explored for new and undescribed bromels, those little
known members of the pineapple family. Tons of new plants
were collected and preserved for Harvard’s Gray Herbarium,
the Smithsonian Institution, the Museu Nacional in Brazil, and
for the Fosters’ own tropical garden in Florida. Over 40 new
species of bromeliads were found.

In this pleasantly written narrative the Fosters describe many
interesting incidents of their adventures. The hazards and hard-
ships of travel over rough country by narrow-gauge railroad,
truck, and horseback were but the prelude to miles, on foot,
through uncut vine-entangled jungle. Extremes of daytime
tropical heat and near zero temperatures at night; protection in
a remote mountain monastery and scant shelter in a primitive
frontier hut; monotonous diet of rice and beans, long periods
of hunger, and gracious meals with hospitable friends: this was
the pattern of life.

Fatigue, often pyramiding to the point of despair, was in-
stantly dispelled by the enjoyment and thrill of discovery. New
orchids, hummingbirds, blond monkeys, crying frogs, and sud-
den encounter with the poisonous snakes that live in leaf cups
of bromels provided experiences running the entire gamut from
delight to extreme danger.

This entertaining book is handsomely illustrated by 137 black
and white photographs, 4 kodachromes, and 32 sketches by
Mulford B. Foster. — Marjorie T. Bingham, Cranbrook Insti-
tute of Science.

Pictorial Handbook of Fracture Treatment, by E. L.

Compere, M.D., and S. W. Banks, M.D.; Chicago: The
Yearbook Publishers, Inc., 1943, 351 pages, $4.25.

This is an interesting and useful book; excellent print, com-
position, well indexed and well illustrated. The discussion of
the subject is divided into five parts: Part I, General Consid-
erations of Treatment; Part II, Fractures and Dislocations of
the Upper Extremity; Part III, Fractures and Dislocations of
Lower Limbs; Part IV, Fractures and Dislocations of the
Trunk; Part V, The Face and Skull. The subject matter in
each chapter follows a specific line with illustrations clearly de-
fining the matter in the text. Each chapter covers a subject in
itself and there is very little duplication in discussing similar
subjects. The illustrations, both line and reproductions of X-
rays, clearly enumerate the situation which may be met by a
practitioner. This book might well be on the desk of any prac-
titioner. In some of the methods of treatment, the authors have
carried the subject into a field where hospital treatment only
could be advised. The volume as a whole would be of great aid
to students and house officers.

In Memoriam

Dr. Chester A. Stewart
1890-1946

The Journal Lancet marks with regret the passing
of Dr. Chester Arthur Stewart, who had been a
member of the Board of Editors of the Journal since
its reorganization in 1929.

Dr. Stewart died on February 8, 1946, in New Or-
leans, of coronary disease. He had been working regu-
larly until that day. Dr. Stewart had been chief of the
department of pediatrics of the Louisiana State Univer-
sity School of Medicine since 1941. Until then he had
been engaged in private practice in Minneapolis and was
clinical professor of pediatrics at the University of Min-
nesota Medical School, of which he was a graduate. He
was also a member of the staffs of Swedish, Abbott, and
St. Barnabas hospitals. In 1934 Dr. Stewart was presi-
dent of the Hennepin County Medical Society, and at
the time he left Minnesota he was a member of the
Council of the State Medical Association.

The Journal Lancet plans to make the special pedi-
atrics issue, to be published in May, a memorial to
Dr. Stewart.

Dr. Charles C. Allen, 60, of Austin, Minnesota,
died February 20, 1946, in Austin, where he had been a
physician and surgeon since 1912. He was past president
of the Southern Minnesota Medical Society and Mower
County Medical Society, and had served as city health
officer and county physician.

Dr. George Edgar Armour, 65, died in January, 1946,
at his home in St. Ignatius, Montana, following a para-
lytic stroke. Dr. Armour is remembered as the physi-
cian of Lambert, Montana, whose herculean efforts dur-
ing the influenza epidemic of 1918 became legendary.
During the worst part of the epidemic, it is reported,
he tended patients for a period of five weeks without
resting long enough to remove his clothes, and sleeping
only as he drove from one house to another. Since 1925
Dr. Armour had been physician on the St. Ignatius
Indian Reservation.

Dr. Herbert Burr Bailey, 63, died February 11,
1946, at Fairmont, Minnesota, of a heart attack suffered
the week before. Dr. Bailey was bom in Jackson, Min-
nesota, the son of a pioneer family. After graduating
from the medical school of the University of Minnesota
he practised first in Ceylon, Minnesota, then in Fairmont.

Dr. William James Cochrane, 79, well-known phy-
sician of Lake City, Minnesota, died February 1, 1946,
following a long illness. He was a graduate of the Col-
lege of Physicians and Surgeons of Chicago (1895), and
practised in Quincy, Illinois, until 1899, when he went

The Journal Lancet

to Lake City. After serving as a captain in the Medical
Corps in World War I he practised in Minneapolis for
three years before returning to Lake' City.

Dr. Cochrane was for many years on the board of
Buena Vista Sanatorium, and for some years was presi-
dent of the Lake City Hospital. Since 1901 he had been
a surgeon for the Milwaukee Railroad. He was a past
president of the Wabasha County Medical Society and
a member of the Minnesota State Medical Association.
Though he had retired some five years ago, Dr. Coch-
rane continued to assist in surgery and to take cases dur-
ing the wartime shortage of physicians. He had been
a member of both the Congregational Church and the
Masonic Order for nearly half a century.

Dr. Henry Oswald Grangaard, 64, of Jamestown,
North Dakota, died February 10, 1946, of a heart ail-
ment. Dr. Grangaard had been physician of the State
Hospital at Jamestown for a year and a half. He had
previously practised at Proctor, Minnesota, and then for
many years at Ryder, North Dakota.

Dr. Walter De Witt Shelden, 76, senior consult-
ant in the section of neurology of the Mayo Foundation,
died at Rochester, Minnesota, February 13, 1946. Dr.
Shelden was a graduate of the University of Wisconsin
and Rush Medical College, and before going to the
Mayo Clinic in 1913 had been clinical professor of medi-
cine at the University of Minnesota.

Dr. Walter L. Vercoe, 84, died January 30, 1946,
at Deadwood, South Dakota, following a short illness.
Dr. Vercoe practised in Deadwood as an eye and ear
specialist for thirty years before his retirement in 1931,
and since then had lived in Florida and in Hot Springs,
South Dakota.

Dr. Vercoe was born in Australia on March 1, 1861,
the son of an English missionary, and was educated in
England. He came to America at the age of 22, studied
medicine in Chicago, and began to practise in Deadwood
in 1900. He was a member of the American College of
Surgeons, the Black Hills District Medical Society, and
the American Medical Association. He was a member
of the State Board of Health for a number of years.
He served as a representative from Lawrence County
at the State Legislature, was an officer of the National
Guard, and served on the Mexican border in 1915 and
1916.

Dr. Morton A. Seidenfeld has been appointed director
of psychological services for the National Foundation
for Infantile Paralysis. In cooperation with the medical
director of the Foundation, he will inaugurate a research
program on the psychological problems and needs of
infantile paralysis patients and will develop a plan for
their psychological treatment. His appointment, accord-
ing to the president, Basil O’Connor, will add an impor-
tant new sphere of activity to the medical program of
the organization.

Views Items

ANNUAL MEETINGS

The Montana State Medical Association will hold its
annual session in Great Falls, July 18-20, inclusive. The
House of Delegates meeting will be held the first day,
and the following two days will be devoted to a scien-
tific program.

The North Dakota State Medical Association will
hold its annual meeting during the spring, in Bismarck,
May 26—28, inclusive. The meeting will be for the en-
tire membership. A feature of the program will be an
open forum on medical care.

The South Dakota State Medical Association, accord-
ing to present plans, will hold its 1946 convention in
Aberdeen, June 1-4, inclusive. Councilors and officers
will meet Saturday, June 1, and the House of Delegates
on Sunday, June 2. The scientific sessions will be held
Monday and Tuesday, June 3 and 4.

NEWS FROM MINNESOTA

University of Minnesota. Dr. Donald Wilson Has-
tings, former chief psychiatrist of the Eighth Air Force
in England, and later chief Air Force psychiatrist in
Washington, has been appointed by the University of
Minnesota Board of Regents as Professor and Head of
the Department of Neuropsychiatry in the Medical
School. Dr. Hastings will fill the vacancy left by the
illness and resignation of Dr. J. Charnley McKinley.

Since his release from the Army in August 1945, Dr.
Hastings has served as Professor of Psychiatry at the
Women’s Medical College in Philadelphia. Dr. Has-
tings received the M.A. (1932) and M.D. (1934) de-
grees from the University of Wisconsin and interned
at Philadelphia General Hospital. He held a Rocke-
feller Fellowship in Psychiatry at the Pennsylvania Hos-
pital and Institute for Nervous and Mental Diseases in
1936-38. He served as psychiatrist of the Students’
Health Service of Harvard University in 1938-39, was
Clinical Director of the Pennsylvania Hospital in 1939—
42, and held an instructorship in psychiatry in Jefferson
Medical College before his military service. He will
assume his duties at the University of Minnesota
March 16.

Dean Harold S. Diehl announces the appointment
of Dr. Robert A. Aldrich and Dr. Clifford G. Grulee,
Jr., to special teaching assistantships in pediatrics, and
Dr. Charles U. Culmer to a similar post in surgery.
Dr. Aldrich holds the B.A. degree from Amherst Col-
lege and the M.D. degree from Northwestern Univer-
sity; Dr. Grulee the B.A. degree from Wayne Univer-
sity and the M.D. degree from Northwestern Univer-
sity; Dr. Culmer the M.D. and Ph.D. degrees from
Northwestern University. The funds for the support
of these special assistantships are provided by the Rocke-
feller Foundation, as part of its program to aid in the
development of selected young men whose preparation
for teaching and research posts was interrupted by mili-

March, 1946

tary service. Additional appointments are under consid-
eration in surgery, neuropsychiatry, and in preventive
medicine and public health.

The University of Minnesota School of Public Health
is one of nine university schools accredited by the Ameri-
can Public Health Association to give the degree of
Master of Public Health for the academic year 1946-47.

Four University of Minnesota men have been appoint-
ed by the National Research Council to help plan a re-
search program for the American Cancer Society. They
are Dr. John J. Bittner, director of the division of
cancer biology at the University, named chairman of a
research panel on the milk factor, to work in the divi-
sion of biology; Dr. Robert Gladding Green, professor
of bacteriology and immunology, named to the panel
on virus, division of biology; Dr. C. P. Oliver, associate
professor of genetics, named to the panel on human
genetics, division of biology; and Dr. Harland G.
Wood, associate in physiology, named to the panel on
isotopes, division of physics. As members of a national
planning body of 91 men, they will direct work aimed
at the conquest of cancer.

Under the plan described in our February issue, in-
tended to improve medical care and expand the staff
at the Minneapolis Veterans Hospital, nine more Twin
Cities physicians have been added to the staff upon
recommendation of the Dean’s Committee, bringing the
total to 22 consultants and seven ward physicians.

Dr. Charles Germo, after fifty years of active prac-
tice, was honored by the community of Balaton, Min-
nesota, upon his retirement in February 1946. Dr.
Getmo is a graduate of the University of Minnesota
Medical School, class of 1895. The Balaton Tribune
of February 7, 1946, pays tribute to the civic and busi-
ness leadership of Dr. Germo, as well as his professional
service. A testimonial banquet honoring Dr. Germo
was held February 8.

"Fifty years of service in one community is a record
that few businesses achieve,” the Minneota Mascot
comments. "When it is accomplished by a 'horse and
buggy doctor’ it is well nigh a miracle. The rigors of
country practice are severe. . . . Our Dr. Germo,

blessed with a rugged physique, has weathered half a
century of strain and stress incidental to looking after
the health needs of our people, and it is indeed fitting
and proper that we who have been beneficiaries of his
work should honor him and his wife on the occasion of
their retirement.”

Dr. William A. O’Brien, director of postgraduate
medical education at the University of Minnesota, speak-
ing at a conference on rural medicine at the Center for
Continuation Study, suggested that "adult specialists”
be developed by the medical profession to care for the
greater number of persons who will be seeking expert
medical care, as a parallel to the child specialists. It is
Dr. O’Brien’s opinion that medical practice during the
war gave a great impetus to the development of small
groups of doctors practising together in small towns,
and that the trend is likely to continue in the postwar
years. The three-day course in rural medical problems

was given for a group of 25 community health leaders
from small towns in Minnesota.

Dr. W. L. Burnap, Fergus Falls, attended the Na-
tional Conference on Medical Services in Chicago in
February.

Dr. Olle Friberg of Stockholm, who came to this
country for training in anesthesiology, observed at the
University Hospitals, Minneapolis, and the Mayo Clinic
in mid-February. He will return to Sweden in April.

Lt. Col. W. R. Schmidt, Worthington, now on ter-
minal leave, has been made a Fellow of the American
College of Surgeons.

The third eye health clinic in a county-wide survey
of school children was held at Forest Lake in February
under the auspices of the Minnesota Society for the
Prevention of Blindness. More than 700 children were
given preliminary tests by the Society’s nurse. Parents
of children showing defective vision are notified and
asked to send the children to the center, where eye spe-
cialists of the University of Minnesota make follow-up
examinations. The physician then recommends needed
treatment in a report the parents may give to the fam-
ily doctor. The Washington County Medical Society
and school officials are cooperating with the program.

The Minneapolis Academy of Medicine held a dinner
meeting at the Minneapolis Club on February 18. Dr.
John F. Pohl spoke on "The Effect of Prostigmine in
Cerebral Palsy,” and Dr. Willis H. Thompson on
"Hereditary Retinoblastoma.” A business meeting and
election of officers followed.

The Minnesota Pathological Society met Tuesday,
February 19, at the University of Minnesota medical
science amphitheater to hear Dr. A. B. Baker and Dr.
H. H. Noran speak on "Pneumonia Encephalitis and
Its Relation to the Blood-clotting Mechanism” and Dr.
W. P. Larson on "A Study of the Properties of Lung
Extracts.”

Dr. E. L. Tuohy, Duluth, speaking on "Future Medi-
cine” before the Kiwanis Club, estimated at about 10
per cent the proportion of the nation’s doctors who
favor the proposed federal health scheme.

The first permanent diphtheria clinic in Minneapolis
has been opened at the public health center, and will
be held for an hour every Saturday morning. The
clinic will be under the direction of Dr. Alex Berger,
and physicians will be supplied through the Hennepin
County Medical Society.

Dr. G. A. Knutson, recently returned from military
service, has taken over the practice of the late Dr.
A. W. Shaleen at Hallock. His coming will offer wel-
come relief to Dr. Anthony Berlin, who has been the
only physician in Kittson County since the death of
Dr. Shaleen, and has also been called to points in Pem-
bina and Roseau counties.

The community of Berlin village has honored with
a testimonial banquet the founder of its community
hospital, Ida Marie Thiel, who organized the Thiel
Hospital in 1923. During its 22 years the hospital has
had 9424 patients, and 1690 babies have been born in
the hospital.

The Journal Lancet

Dr. Harry E. Caldwell has assumed charge of the
Veterans’ Hospital in Minneapolis.

The Nicollet Clinic, Minneapolis, announces the re-
turn from military service of Dr. Gordon G. Bowers
and Dr. Ray F. Cochrane, and their association with
the clinic. Also resuming practice after military service:
Dr. Paul C. Benton, Gibbon; Dr. M. P. Viring, Wells.

Dr. F. E. De Godoy Moreira of Sao Paulo, Brazil,
spent a week at the Mayo Clinic recently as part of an
extensive tour of American hospitals and medical insti-
tutions, to observe techniques of orthopedic surgery.
"The purpose of my visit,” he said in an interview, "is
to see the development of new things, to enjoy an inter-
change of ideas, and to develop friendship and coopera-
tion between the doctors of this country and those of
my country, in the interest of the improvement of scien-
tific information.”

NEWS FROM MONTANA

Dr. H. E. Mortensbak, after two years at New Ulm,
Minnesota, has located at Great Falls, where he has
taken over the practice of Dr. C. E. Anderson, who
has retired.

Dr. Charles R. Lyons, formerly of Parker, Indiana,
has located in Drummond, in western Montana. Dr.
Lyons, a graduate of Ohio State University Medical
School in 1941, will be Drummond’s first physician in
two years.

Resuming practice after service : Dr. M. L. Fisher,
Hardin; Dr. C. J. Bresee, Great Falls; Dr. Raymond
Polk, formerly of Memphis, Tennessee, in Miles City;
Dr. R. Lawrence Casebeer, Butte.

A committee of county and city officials and repre-
sentatives of medical and dental associations and school
districts is studying the advisability of merging county,
city, and school district health offices into a full-time,
over-all health department in Billings.

The Yellowstone Valley Medical Society will sponsor
in May its first state-wide spring clinic since prewar
years.

Dr. W. F. Hamilton, Havre, has been appointed coun-
ty health officer of Hill County by the board of county
commissioners.

Dr. D. C. Epler, formerly of Williston, North Da-
kota, and now on terminal leave from the Army Med-
ical Corps, has begun practice in Bozeman.

The Kalispell General Hospital has elected Dr. H.
D. Huggins as president of its medical staff; Dr. J. A.
Brassett, vice president; Dr. R. L. Towne, secretary-
treasurer.

Dr. Cecil M. Hall has returned to the eye, ear, nose,
and throat department of the Great Falls Clinic, fol-
lowing his release from the Army Medical Corps as a
major. He was stationed for a time near Salisbury,
England, and attended several meetings of sections of
the Royal College of Surgeons.

Dr. F. H. Crago has also returned to the Great Falls
Clinic as internist after more than five years of service,
during which he became group surgeon for the 14th
fighter group of the Air Force in Italy.

Dr. Mary E. Martin of Chicago has been appointed
director of clinical laboratories at St. Vincent Hospital,
Billings.

NEWS FROM NORTH DAKOTA

Dr. L. J. Alger of Grand Forks attended the Mid-
Winter Post-Graduate Clinical Convention in Los An-
geles, California, in January. He solved the transpor-
tation problem by flying his own Stinson Voyager to
Los Angeles.

At Grand Forks school health clinics are being organ-
ized and conducted by the two city nurses under the
direction of Dr. Louis B. Silverman, city health officer,
with the assistance of local physicians, nurses’ aides, and
P.T.A. members. Dr. Silverman, who has returned from
two years’ service with the Army Medical Corps, has
been appointed city health officer, succeeding Dr. T. Q.
Benson, who remains county health officer. Dr. Silver-
man was formerly assistant professor of medicine at the
University of North Dakota.

Dr. John E. Ruud of Grand Forks is now associated
with the Doctors Fawcett at Devils Lake in the practice
of general medicine. Dr. Ruud interned at St. Barna-
bas Hospital, Minneapolis.

Dr. Thomas M. Cable, formerly of Cleveland, Ohio,
has started practice in Hillsboro following discharge
from military service. His wife is a native North
Dakotan.

Dr. Robert Blatherwick, after service in the Army
Medical Corps, is associated with his father, Dr. W. E.
Blatherwick, at Parshall, in the practice of medicine.

Dr. H. G. Cleary, who has returned from duty with
the Army Medical Corps, has been appointed physician
at the Sharon Community Hospital.

Lakota, county seat of Nelson County, is advertising
for a physician to locate there. According to the Ford-
ville Tri-County Sun there is no practising physician in
Nelson County, one of the larger counties of North
Dakota.

Plans have been completed for the construction of
the Johnson Clinic at Rugby, where Drs. O. W. John-
son, C. G. Johnson, William Fox, and Ted Keller will
be associated. Construction is expected to start in May.

Resuming practice in North Dakota: Dr. Charles B.
Darner, Fargo Clinic, after serving at Saipan, Tinian,
and Iwo Jima, and in Japan; Dr. E. K. Ingebrigtson,
Moorhead Clinic; Dr. James R. Dillard, Fargo, after
two years in the Pacific area with the Army Medical
Corps.

NEWS FROM SOUTH DAKOTA

Officers and councilors of the South Dakota State
Medical Association held a meeting at the Marvin
Hughitt Hotel, Huron, Sunday, January 27, with all
officers and a majority of the councilors present. In
addition, Dr. Gilbert Cottam and Dr. A. Triolo of the
State Board of Health, Pierre, Mr. Karl Goldsmith,
Pierre, legal adviser of the Association, and Dr. G. T.
Jordan, Dean J. C. Ohlmacher, and President I. D.
Weeks, all of the University of South Dakota, also
attended.

March, 1946

Dr. M. W. Larson, Watertown, was elected to fill
the unexpired term of Dr. H. R. Brown as Councilor
of the Watertown District. Dr. Brown is now Vice
President. Reports of various conferences attended by
the officers in Chicago, St. Paul, and St. Louis, were
given by Drs. Duncan, Robbins, Brown, and Mayer.
Dr. N. J. Nessa, Delegate, reported upon the House
of Delegates session of the American Medical Associa-
tion. Plans for the four-year medical school for the
University of South Dakota were presented by Presi-
dent I. D. Weeks and Dean J. C. Ohlmacher.

Dr. Nelius J. Nessa of Sioux Falls announces the
association of Dr. Donald H. Breit in the practice of
radiology in the Sioux Falls Clinic. Dr. Breit was for-
merly at the University of Nebraska.

Dr. E. T. Plowman has left with his family from
Marble, Minnesota, where he has been associated with
the Mesaba Clinic for ten years, to become associated
with a Brookings, South Dakota, clinic..

Dr. R. E. Jernstrom of Rapid City announces the
association of Dr. John W. Erickson in a new medical
partnership. Dr. Erickson practised in Minneapolis and
Jackson, Minnesota, before joining the Army in late
1939, and is now on terminal leave as a lieutenant
colonel.

Dr. Gordon S. Owen of Rapid City, who has recently
returned from service, has been appointed temporary
acting director of the Pennington County Health De-
partment, succeeding Dr. I. H. Mauss, by Dr. Gilbert
Cottam.

The recently organized Memorial Hospital Associa-
tion of Canova is looking for a physician to reopen
the Canova Hospital, closed since the death of Dr.
Madsen two years ago.

Dr. John E. Dunn, formerly of Groton, has joined
the medical staff of Battle Mountain Veterans Facility,
succeeding Dr. Jack Dworin.

Dr. George T. Jordan, eye, ear, nose, and throat
specialist of the staff of Loyola University, and prac-
tising physician in Chicago, has been added to the staff
of the University of South Dakota Medical School,
which will begin operation on a four-year basis in Sep-
tember. Dr. Jordan is a Fellow of the American Col-
lege of Surgeons and the American Medical Association
and a senior member of the American Academy of
Ophthalmology and Otolaryngology.

Dr. L. G. Leraan, Sioux Falls, has been appointed
county physician of Minnehaha County, succeeding Dr.
J. A. Kittleson.

Dr. Harold P. Adams of Huron has resumed his
duties in surgery at Huron Clinic and Sprague Hos-
pital after 42 months in the Army Medical Corps,
14 of them overseas.

Dr. W. A. Delaney, Jr., of Mitchell, has resumed
medical practice with his father after 22 months of
service with the Navy in the Pacific.

Dr. B. R. Skogmo, formerly of Watertown, is now
associated with Dr. J. M. Butler, a contributor to the

January Journal Lancet, in the Black Hills Clinic at
Hot Springs, South Dakota.

Dr. Kurt Tauber has left the state hospital at Yank-
ton for Wagner, South Dakota, where he will be asso-
ciated with Dr. Thomas A. Duggan.

The Fourth District Medical Society, meeting at
Pierre on January 25, heard a discussion of a proposal
from the Farm Security Administration for a full cov-
erage surgical, medical, and hospitalization plan to apply
to all rural families regardless of income and to all
urban families with incomes of less than $3,000 a year.
The newly elected officers of the society are Dr. O. A.
Kimble, Murdo, president; Dr. Gilbert Cottam, Pierre,
vice president; Dr. M. M. Morrissey, Pierre, secretary-
treasurer; Dr. C. E. Robbins, Pierre, councillor; and
Dr. Morrissey, delegate to the state convention.

The Third District Medical Society of South Dakota
held their regular quarterly meeting at the Bates Hotel,
Brookings, in late February. Members, the Ladies’ Aux-
iliary, and guests met at 6:30 for dinner, with a scien-
tific program following. The guest speaker was Dr. Jan
H. Tillisch of the Mayo Clinic, who presented a lantern-
slide illustrated lecture on "Advances in Medicine in
World War II.” He elaborated on the diagnosis and
treatment of rheumatic fever and infectious hepatitis.
Indications and contraindications for the transportation
of various types of patients by air were also discussed
at length. The next meeting of the society will be held
in Madison, South Dakota, at a time to be announced
later.

The Black Hills (Ninth) District Medical society met
at Homestake Hospital, Lead, on February 21, for a
program including the presentation of the following
papers: Dr. P. P. Ewald, "Remarks on the Rh Factor”;
Dr. C. A. Soe, "Experiences in a Base Hospital in the
Pacific”; and Dr. H. E. Davidson, "Some U. S. Army
Methods of Treating Tropical Diseases.”

NEWS OF HOSPITALS

Into the Journal Lancet office during the past
month has come news of increasing activity on the hos-
pital front.

At the University of Minnesota institute on rural
medicine, the superintendent of University Hospitals,
Ray M. Amberg, pointed out that six Minnesota counties
have no hospitals, and that the only way to build the
needed hospitals in the northern part of the state is
through government subsidy. The $1,600,000 that would
be allocated to Minnesota for this purpose, for five years,
under the Hill-Burton bill is only a fraction of the
amount needed, Mr. Amberg said, since present con-
struction plans call for the expenditure of between $40
million and $50 million. Careful study, planning, and
legislation will be required, he stated, to build facilities
in rural areas which will attract competent doctors.

Addressing the same group, Dr. William A. O’Brien,
director of postgraduate medical education at the Uni-
versity, pointed out the need for training general prac-
titioners to serve the rural areas and to replace the older

The Journal Lancet

men who "grew up with medicine.” At a time when the
trend is overwhelmingly toward specialization, he said,
the matter is an important one, because the small hospi-
tals that will be built in rural areas will call primarily
for general medical men, not specialists.

Karlstad, Minnesota, a community of 700 people on
the northern border, which at present has no resident
doctor, has organized to provide itself with medical and
hospital facilities. It is looking for a "young physician
with a penchant for conducting a country doctor type of
practice.” Following the organization in December 1944
of the Karlstad Memorial Fund Foundation, which had
25 group members by the end of 1945, the community
has collected a total of $9,600 in its hospital fund drive.
Several committees are at work clearing the way for
construction of a modern, community-financed hospital,
on which building is expected to begin soon. The doctor
Karlstad seeks would have control of this hospital. Work
to complete incorporation of the hospital is under way.

Wesley Hospital, Wadena, Minnesota, reports a total
of 1974 patients and 415 births in 1945.

Dr. O. F. Mellby has been re-elected president of the
Oakland Park Sanatorium near Thief River Falls, which
is owned and maintained jointly by four counties — Ro-
seau, Marshall, Pennington, and Red Lake. Dr. Mellby
has been president of the commission for more than
25 years.

St. Barnabas Hospital, Minneapolis, has named Dr.
Miland E. Knapp, assistant clinical professor of physical
medicine at the University of Minnesota and president
of the American Congress of Physical Medicine, chief
of staff for 1946. Dr. Joseph P. Spano*, recently re-
turned from service, is the new vice chairman; Dr.
William E. Proffitt, secretary; Dr. H. D. Giessner,
executive committee member. Dr. Carl O. Rice, retiring
chief of staff, also becomes a member of the executive
committee.

St. Mary’s Hospital, Duluth, has named Dr. J. E.
Power chief of staff; Dr. A. J. Spang, staff secretary;
Dr. L. R. Gowan, chief of staff elect; Dr. Frank Cole,
chief of anesthesiology; Dr. J. A. Winter, eye, ear, nose,
and throat; Dr. Richard Bardon, medicine; Dr. R. J.
Moe, obstetrics; Dr. M. H. Tibbetts, orthopedics; and
Dr. M. A. Nicholson, chief of urology. Department
heads renamed include Dr. E. L. Tuohy, laboratory;
Dr. C. W. Taylor, contagion; Dr. L. E. Schneider,
neurology; Dr. R. E. Nutting, pediatrics; and Dr. F.
J. Elias, surgery.

In Montana hospital administrators, trustees, and su-
pervisors met in Helena late in January for a two-day
session of the governor’s hospital survey committee and
the annual meeting of the Blue Cross Hospital Service
Association of Montana. Chairman Milo Dean of the
steering committee reported to the hospital survey com-

mittee, which has been studying the state’s hospital needs
since July 1945. Systematic relationships between large
and small hospitals must be developed, he said, so that
rural centers may benefit from the research and scien-
tific knowledge gained in larger centers.

Fully a dozen communities in Montana are planning
new hospitals largely based on their own needs and re-
sources, with little thought of whether their hospital
will integrate its services into the larger plan, according
to the chairman, who is administrator of the Montana
Deaconess Hospital in Great Falls. An integrated plan
would work to the benefit of all. "Unfortunately,” said
Mr. Dean, "there is no universally applicable plan for
accomplishing this integration. This is the purpose of
our hospital survey.”

Dr. Carl F. Kraenzel of Montana State College,
Bozeman, reported that Montana now has 69 hospitals,
with 6.9 beds for every 1000 persons. Proposed additions
to hospital facilities would bring the ratio up to 10.2
beds per thousand. Dr. Kraenzel proposed division of
the state into 13 public health program areas in relation
to trade regions, type of farming areas, existing and
proposed transportation facilities, geographic barriers,
and other factors. The coordinated plan proposed in-
cludes health centers, rural hospitals to serve as a me-
diary between health center and district hospitals, and
district hospitals, where major surgery and various spe-
cialties would be available.

In North Dakota, hospitals approved by the American
College of Surgeons in its 28th Hospital Standardization
Survey include: Bismarck, Evangelical and St. Alexius;
Devils Lake, General; Dickinson, St. Joseph’s; Fargo,
St. John’s and St. Luke’s; Grand Forks, Deaconess and
St. Michael’s; Jamestown, North Dakota State, Trinity,
and Jamestown; Minot, St. Joseph’s and Trinity; Rugby,
Good Samaritan; San Haven, North Dakota State Tu-
berculosis Sanatorium; Valley City, Mercy; Williston,
Good Samaritan and Mercy. Provisionally approved:
Bottineau, St. Andrew’s; Grafton, Deaconess; Langdon,
Mercy.

Hazen, North Dakota, which has raised funds for a
new hospital, has been granted its request for a hospital
to be established by the Lutheran Hospitals and Homes
Society of America, which met for a two-day quarterly
meeting in Fargo in January.

Westhope, North Dakota, has conducted a campaign
to raise $60,000 to build and equip a 22-room hospital
in Westhope. A charter has been secured for the West-
hope Memorial Hospital. The Lutheran Hospitals and
Homes Society has been asked to take over management
of the new hospital. A large area is expected to benefit
from the proposed hospital.

A charter has been granted to the Memorial Health
Center of De Smet, South Dakota, a nonprofit clinic
and hospital corporation.

March, 1946

The Kingsbury County Hospital, Lake Preston, South
Dakota, has been incorporated in articles filed with the
secretary of state.

Huron, South Dakota, has raised more than half the
funds required for the construction of a Lutheran Mem-
orial Hospital, and construction will begin as soon as
materials and labor are available.

State Licensing of General Hospitals
Proposed

To protect the public and hospitals themselves from
poor services and inadequate facilities, state licensing of
all general hospitals was proposed to officers of hospital
organizations by Dr. Charles Wilinsky, administrator of
Beth Israel Hospital in Boston and chairman of the
American Hospital Association’s Committee on Model
Licensure Law. Representing hospitals in the United
States and Canada, through state, regional, and provin-
cial hospital associations, the group met February 8 and
9 to discuss problems and exchange ideas in the Mid-
Year Conference of the Association in Chicago’s Drake
Hotel.

"Ten states now have licensing laws for general hos-
pitals,” stated Dr. Wilinsky. "Six failed to pass similar
laws in 1945. In many states, under prevailing condi-
tions, almost any institution offering bed care may term
itself a 'hospital’. The American Hospital Association,
by formulating a model bill incorporating the best fea-
tures of many laws now in force, hopes to encourage the
adoption of general hospital licensing laws in all states.
Such laws, to be effective, must be accompanied by a
provision for adequate funds to provide regular hospital
inspection by a competent staff of state or hospital
personnel.”

The care of veterans in community hospitals was
voted all possible cooperation by the group. "Already
several hundred hospitals in the nation have contracted
with the Veterans Administration to care for male vet-
erans with service-connected disabilities and for female
veterans,” said John N. Hatfield of Philadelphia, chair-
man of the Council on Government Relations.

To facilitate immediate care for these men and women
in their own communities and to ease the load on vet-
erans’ hospitals, the Association has agreed to furnish
as many as 20,000 civilian hospital beds by September
1946. A resolution was passed approving the principle
of utilizing an intermediary agency to handle the fiscal
relationships between the Administration and the hospital
rendering the service. The Michigan Hospital Service
(Blue Cross) is performing this service in that state.

Resolutions proposing that hospitals make staff posi-
tions available to returning veteran physicians as soon as
possible, and urging the continued service of volunteers
in civilian hospitals in view of sustained nursing short-
ages, were passed by the group.

Employee pension plans, nurse relations, and the ex-
pansion of medical and Blue Cross voluntary prepayment
plans were discussed among hospital and hospital asso-
ciation problems and progress.

Commission on Hospital Care Report

Expansion of services of the large general hospital
to include tuberculosis and nervous and mental care may
well take place in the future, suggested Arthur C.
Bachmeyer, M.D., at the Mid-Year Conference Febru-
ary 8 and 9 of the American Hospital Association. The
director of study of the Commission on Hospital Care,
an independent public service committee studying hos-
pital facilities in the United States and initiated by the
Association, Dr. Bachmeyer spoke before officers of hos-
pital organizations of the United States and Canada.

Discussions of the relation of the general hospital
to all types of health care bring the following considera-
tions to the fore, Dr. Bachmeyer, told the conferees:

The advisability of constructing new tuberculosis
facilities adjacent to and operated in conjunction with
large general hospitals.

The provision of facilities in large general hospitals
for diagnosis of nervous and mental patients, and for
treatment of those patients not in need of long-term
institutional care.

The feasibility of expanding the functions of special
communicable disease hospitals now operated by cities,
towns, and villages to include all types of illness.

Other proposals related to the group by Dr. Bach-
meyer were: the possibility of the maintenance of nurs-
ing schools by large institutions only, which would affili-
ate for rural hospital experience with hospitals in smaller
communities; improved hospital care for Negroes; and
the computation of the need for hospital beds in local
or state-wide areas based upon the ratio between the
death rate and the days of hospital care.

"Action on state surveys of hospital facilities has now
been taken in every state and in the District of Colum-
bia,” he said. "Thirty-one surveys are now actually in
progress.

"Because developments have come rapidly, the Com-
mission feels that it can complete its work by October
1, 1946, the termination date of the original two-year
allotted period,” stated Dr. Bachmeyer.

It is expected that the Commission’s report will be
published shortly thereafter.

The Care of Communicable Disease:

As It Developed*

The plague, leprosy, and typhus were the fearful
enemies of the public health which all through early
periods of history focused attention upon the need for
rigid control of those who were infected with contagious
disease. But because of ignorance of the causes of these
illnesses and the assumption that the afflicted were being
punished by divine dictate, the adopted method was
complete isolation of infected sections of communities,
whole cities, and sometimes wide geographic areas. Un-
fortunate victims were left to live or die according to
the pleasure of the Gods.

The advent of Christianity changed these conditions.
The adherents to this new, compassionate religion accept-
ed the responsibility of visiting the sick and ministering

The Journal Lancet

to their needs. Food and shelter were provided for the
stricken and the destitute. Through observation by
those who tended these unfortunates, the communicable
nature of their illnesses soon became apparent. Lacking
effective methods of treatment, isolation hospitals were
set apart from cities and from avenues of traffic. Most
of these isolation units were temporary buildings which
were abandoned or destroyed as soon as the "scourge”
had passed. They were then re-established in new loca-
tions when the need arose again.

There was no differentiation of the various diseases in
these isolation units. Even in the relatively few continu-
ously operated hostels, all types of patients were ad-
mitted.

Late in the nineteenth century, Koch, Pasteur, and
their contemporaries demonstrated the relation of bac-
teria to the cause and spread of contagious diseases. The
communicable nature of many illnesses was recognized,
but methods of transmission were debated. The lack of
full understanding of the nature of disease and the man-
ner in which it spread led to renewed emphasis upon the
need for isolating patients afflicted with communicable
diseases.

Scientists then engaged in a long period of contro-
versy over the relative merits of the theories of air-borne
versus contact methods of the transmission of infection.

During this period of development in the science of
bacteriology, contagious disease patients again had been
isolated, usually in separate buildings, from those with
other illnesses. They provided much of the clinical ma-

terial from which the present techniques for the control
of contagion were evolved. Earlier it had been observed
that a person suffering with a contagious disease was
a source of infection for others. It now was discovered
that the establishment of a barrier around the infected
person, across which no contaminated articles were
passed, would interrupt the transmission of infection.

Methods of treatment, organization of procedures, and
training of personnel, supplementary to those considered
necessary for the care of ordinary illness, were estab-
lished in communicable disease hospitals. The develop-
ment of these techniques, the trend toward specializa-
tion in medical practice, the differentiation between com-
municable and noncommunicable disease, and placement
of emphasis upon public health programs, which includ-
ed public support for the maintenance of institutions
designed to improve or protect public health, influenced
the construction of' special contagious disease hospitals
financed from tax funds or operated with subsidies from
public resources.

Thus from the beginning of organized care for illness,
when contagious disease patients were outcasts of society,
and through periods when they were housed in tempo-
rary isolation units, then admitted to general hospitals
and later treated in separate contagious disease hospitals,
w.e have come to a time in the development of medical
science when methods for the care of this type of patient
are again being revised.

*From the Hospital Survey News Letter, January 1946.

COLLEGES IN NEED OF PHYSICIANS

The American Student Health Association directs attention to the following colleges and universities in need of physicians.
College or University Person in Charge Position

Pennsylvania State College, State College, Pennsylvania ___J. P. Ritenour, M.D. Man assistant

University of Maine, Orono, Maine Joseph M. Murray,

Health Service Committee Director

University of Alabama, University, Alabama ... ..... .Noble B. Hendrix,

Dean of Students Director

Alabama Polytechnic Institute, Auburn, Alabama J. W. Dennis, M.D Full-time woman physician

University of Florida, Gainesville, Florida Embree R. Rose, M.D Associate in Department,

salary $5000 a year

University of New Hampshire, Durham, New Hampshire __ President Fred Engelhardt Man physician

University of Michigan, Ann Arbor, Michigan __ Warren Forsythe, M.D. .. . Woman physician

State University of Iowa, Iowa City, Iowa C. I. Miller, M.D Man physician

Iowa State College, Ames, Iowa J. A. Grant, M.D ?

State College of Washington, Pullman, Washington President E. O. Holland .... Assistant physician

Ohio University, Athens, Ohio E. H. Hudson, M.D. Assistant physician

Union College, Schenectady, New York President Benjamin P. Whitaker Physician

Lehigh University, Bethlehem, Pennsylvania .... President Clement C. Williams Assistant director

University of Missouri, Columbia, Missouri Dan G. Stine, M.D. Young woman physician

Northern Illinois State Teachers College, DeKalb, Illinois President Karl L. Adams .. Man physician

University of Nebraska, Lincoln 8, Nebraska L. E. Means, M.D Staff technician

Michigan State College, East Lansing, Michigan _. .... C. F. Holland, M.D. 1 man physician, 1 woman physician

New York State Teachers College, Cortland, New York President Donnal V. Smith Director

Colorado State College of Education, Greeley, Colorado President George W. Frasier 1 man physician, 1 woman physician

University of Illinois, Urbana, Illinois J. Howard Beard, M.D. 2 women physicians, 1 man physician

Montana State University, Missoula, Montana Donald M. Hetler, 1 man physician with

Chairman, Health Committee training in psychiatry

University of Wisconsin, Madison 6, Wisconsin Annette C. Washburne, M.D 2 assistant physicians

University of Wyoming, Laramie, Wyoming President G. D. Humphrey Man physician

SPECIAL TUBERCULOSIS NUMBER
Jay Arthur Myers, M.D., Editor

Tuberculosis and War

Kendall Emerson, M.D.

Managing Director, National Tuberculosis Association

New York City

In this country the dreaded postwar upturn in tuberculosis mortality has not occurred.
The estimated rate for 1945 is well below that of the previous year. Several reasons may be
cited for this happy circumstance, among them the inclusion of chest X-rays in examination
of recruits for the armed forces. From this procedure a threefold benefit accrued: contact

infection among the fighting men was noticeably reduced; many early cases found, though
unfortunately not all, sought proper treatment; and, perhaps most significant of all, there was
wide educational value in this huge example of the mass X-ray process itself.

The public was not slow to grasp the diagnostic importance of chest X-rays for the appar-
ently healthy. The facts revealed at induction centers called physicians’ attention anew to
their obligation to discover and treat tuberculosis in its incipient, symptomless stage.

Fifty years ago Dr. Fitz at Fdarvard taught that in no baffling case could differential diag-
nosis be called complete till tuberculosis had been ruled out. Today the general practitioner
has the means, denied to earlier physicians, for carrying out this teaching, namely, the tuber-
culin test and the X-ray.

Finally, it must be borne in mind that mortality and infection rates are not the same.
The decline in infection rates lags far behind. A large residual pool of potential infection
still remains, against which the public can be protected only by discovery and adequate treat-
ment of the potential spreader in his nonbacillary period.

The Journal Lancet

The Relationship of Tuberculosis and Silicosis

O. A. Sander, M.D., F.A.C.P.

Milwaukee, Wisconsin

It has long been recognized that the tuberculosis death
rate among industrial workers exposed to siliceous
dusts exceeds that of the population as a whole. This
influence of silica on the susceptibility of tissues to in-
fection by the tubercle bacillus has been shown both
pathologically by extensive animal experimentation and
clinically by numerous industnal surveys. Dusts that are
low in free silica, such as hematite, marble, gypsum, lime-
stone, and coal, have no such effect. As the free silica
(SiOj) content in dusts increases, however, as with
granite, chalcedony, and quartz, so also does the tuber-
culosis morbidity and mortality increase, approximately
in direct proportion with the silica.

Explanations for this apparently specific effect of silica
have interested certain groups of tuberculosis workers
and pathologists for the past twenty to twenty-five years,
notably Gardner and his co-workers at the Saranac Lab-
oratory for the Study of Tuberculosis, Kettle in Eng-
land, and the Banting Institute in Canada. An evalua-
tion of their work requires an understanding of the early
pathogenesis of both silicosis and tuberculosis and the
numerous points of similarity. Both become established
by way of inhalation of silica particles or tubercle bacilli
into the lung alveoli, and both bring into play the same
defense mechanism to rid the lungs of the foreign ma-
terial. Both are ingested by endothelial cells or phago-
cytes, which carry them through the alveolar walls into
the lymphatic channels, whence they are transported to
the lymph glands at the root of the lung. Here the
early tissue response is entirely similar for both, since
fibroblasts form around them to wall them off.

It has been shown by Fallon that the action on the
phagocytic cell of both tubercle bacilli and silica particles
liberates toxic phospholipids, and that these substances
are responsible for the further proliferation of fibro-
blastic cells, resulting in granulomatous nodules. (While
interesting, this observation never has been substantiated.)
With the tubercle bacillus, the resulting fibrotic nodules
are called "tubercles”; with the silica particle, they once
were known as "pseudo-tubercles,” so similar is their
early histologic appearance.

Some authorities, in fact, have felt that silicosis could
not develop in a nontuberculous lung and that the sili-
cotic nodule always is a silicotic tubercle. The French
investigator Policard was the principal advocate of this
theory, but it has had little support elsewhere. Exten-
sive animal and clinical investigation has definitely estab-
lished the fact that silicosis can develop in lungs that
have never been the seat of tubercle formation. Both
types of nodules, therefore, the silicotic and the tubercle,
may become localized in the same lymph gland and may
develop side by side.

Because of this close proximity of the silicotic and
tuberculous reaction in lymphatic tissues, the maximal

opportunity exists for the silica effect on tubercle bacilli.
Price showed that when silica was added to the artificial
culture medium a more luxuriant growth of tubercle
bacilli resulted. Neither Gardner nor Kettle could con-
sistently verify this in vitro observation. Kettle demon-
strated that subcutaneous lesions due to the presence of
silica are favorable foci for the localization and prolifera-
tion of intravenously injected bacilli. Such proliferation
did not occur in necrotic areas produced by such irritat-
ing agents as turpentine and calcium chloride. Using
the same method, Vorwald and Landau showed that the
injection of nonsiliceous dusts caused no unusual multi-
plication of bacilli. Gardner has demonstrated repeatedly
that the intravenous injection of human bacilli of low
virulence into silicotic rabbits causes progressive tubercu-
losis, whereas the same strain of bacilli injected into non-
silicotic animals causes no progressive disease.

All these observations tend to prove the specificity of
the silica reaction, which appears to furnish a medium
in which tubercle bacilli multiply with increased rapidity.
Gardner believes that, not the silica itself, but chemical
products liberated by the action of silica on the tissues,
are the stimulating factor. He bases this belief on the
presence of large numbers of bacilli in fresh necrotic
silicotic foci and their paucity in silicotic lesions that are
old and without degenerative changes. The precise factor
remains to be demonstrated and is the object of much
continued investigation.

Were this stimulating or activating effect the only
factor in the relationship between silicosis and tubercu-
losis, all cases in which they are combined in the same
lung would be of the rapidly fatal phthisis-florida type
of "galloping consumption.” Only rarely, however, is
this the situation with silico-tuberculosis. Clinically, it is
the most chronic type of tuberculosis one sees, with dense
overgrowth of fibrous tissues. The fibrosis produced by
the silica appears to fortify that laid down by the tuber-
culosis to such a degree that a dense fibrotic barrier is
set up between the viable bacilli and the rest of the
lung. So effective is this barrier that clinical evidence
of activity of the tuberculous focus is often entirely
lacking for many years. Because toxic products from
the bacilli fail to get into the blood stream, even the
tuberculo-allergy may become depressed. Because of de-
creased blood and lymph supply to the tuberculous focus
and the low oxygen tension in the sequestered area, the
bacilli are scarcely able to maintain themselves. They
may lie completely dormant for many years, and in some
cases for a lifetime. With such individuals the silicosis
may even have been beneficial in prolonging life or sav-
ing the life of one who would have developed an earlier
progressive tuberculosis.

Unfortunately, in the majority of such cases silica-
laden phagocytes eventually filter into the caseous area

April, 1946

and produce further silica reaction. The dormant but
viable bacilli in turn are stimulated to multiply and the
silico-tuberculous lesion is stimulated to proliferate and
spread. This process may continue very slowly for many
years, still without clinical evidence of active infection.
Eventually, however, enough of the proliferating bacilli
may work their way out to the surface of the lesion,
there to multiply more rapidly and spread to other areas
of the lung. Bacilli now will be found in the sputum
for the first time, and the clinical symptoms of active
tuberculous disease will develop.

Mode of Onset

Although this is the usual result of the close proximity
of the silicotic and tuberculous reaction in the same lung,
clinically many cases do not fit this pattern. The end
picture depends to a considerable degree on the condi-
tion of the lungs at the time dusting begins, as well as
on the time the reinfection tuberculous infiltration occurs
as related to the dusting. Four main possibilities are
recognized:

1. An active or quiescent tuberculous lesion already
present in a lung before silica invades these organs,
(a) Primary infection focus in the lung parenchyma or
regional lymph nodes, or both, (b) Reinfection tuber-
culous lesion in the lung parenchyma, usually in the
apices of the upper or lower lobes.

2. Invasion of the lungs by tubercle bacilli and free
silica particles, more or less at the same time.

3. Obsolete and well calcified sterile tuberculous scar
or scars in the lung parenchyma or lymph nodes before
silica invades the lungs.

4. Invasion of the lungs by tubercle bacilli after a
nodular silicosis is already present, either primary or
reinfection.

The first two possibilities could be grouped together,
because both follow more or less the same pattern, de-
pending largely on the amount of dust inhaled, its con-
tent of free silica, and the relative amount and type of
the nonsiliceous components. Assuming for the moment
that the dust is almost entirely free silica, in particle
sizes less than 5 micra in diameter, and in sufficient
quantity to produce a nodular silicosis in a few years,
its original effect appears to be to aid nature by accu-
mulating in excessive quantities around the tuberculous
tissue and building around it a dense wall of fibrosis.

From then on the clinical course of most of these
cases becomes chronic. The disease does not become
manifest for many years, often not until the sixth or
seventh decade, and sometimes never.

This typical progressive combined lesion is usually
referred to in this country as silico-tuberculosis, but is
known as tuberculo-silicosis to the South African inves-
tigators. This unfortunate difference in terminology has
resulted in some confusion, but its use has become so
well fixed in America that the term "silico-tuberculosis”
is used throughout this review for the progressive com-
bined lesion.

Not all cases become chronic, however, because when
the preceding tuberculous lesion is quite extensive or the
invasion of bacilli massive, extension and excavation may
occur before any significant fibrotic barrier has had time

to develop. That such cases are in the minority is shown
by the relatively few active tuberculosis cases found in
the early age groups in surveys of dusty trades, as com-
pared with the numerous chronic fibrotic cases. In other
words, these clinical surveys have shown that the in-
creased incidence of tuberculosis in the silica dusty trades
is confined to the group with associated silicosis. Ordi-
nary uncomplicated tuberculosis has been shown to be
no more prevalent in these trades than in trades involv-
ing no silica exposure. Dust exposure must have been
long enough and intense enough to develop a recogniz-
able silicosis before an associated tuberculosis can be said
to have resulted from the dust exposure.

Cases of silico-tuberculosis confined to the regional
lymph nodes at the roots of the lungs are relatively
uncommon. The author has observed two cases of acute
miliary tuberculosis in which post-mortem studies re-
vealed that the only caseous foci to be found were in
the root glands, which also were silicotic. One of these
workers was 69 and the other 60 years of age at death.
The only logical explanation was that the accumulating
silicosis in the root glands had kept alive a pre-existing
primary tuberculous infection in these glands. The lungs
themselves had shown only a slight amount of nodular
silicosis before the hematogenous spread of tubercle ba-
cilli late in life from the infected glands.

One wonders, as a matter of fact, why these combined
lesions in the root glands are not a common finding.
It is in these glands that both the silicotic reaction and
tubercle formation occur first, giving the maximal op-
portunity for intimate association of tubercle bacilli and
silicotic tissue reaction. The fact that this is one of the
rarest forms of silico-tuberculosis suggests that the pri-
mary infection in these glands dies out as calcium de-
posits develop, and the glands have become sterile in
most cases by the time silicosis occurs in adult life. This
observation bears out the finding of Feldman and Bag-
genstoss that viable tubercle bacilli are found only rarely
in the calcified root glands of adults.

When the silica content of inhaled dust is low and
the nonsiliceous components high, the stimulating factor
on tuberculous tissue is lessened and the resulting com-
bined lesion has a lesser tendency to progress. The in-
haled dust has the same tendency, however, to accumu-
late in excessive amounts around the tuberculous lesions
and there add to the fibrosis laid down by the tubercle
bacilli. If the amount of infection was slight, it may
completely die out, leaving nothing but a dense over-
growth of fibrous tissue.

This finding is characteristic with soft coal miners,
post-mortem studies of whom often show dense fibrotic
and contracted upper lobes with secondary emphysema
below. Microscopic tissue studies frequently show no
remnants of the previous tuberculous tissue within the
fibrotic areas. Iron miners whose dust exposures were
relatively low in silica have shown similar lesions. The
fact that the fibrotic areas are usually in the upper lobes
strongly suggests their tuberculous origin, even though
such an origin cannot be proved in all cases. In cases
in which the pre-existing, tuberculosis was more extensive
or where the new infiltration is considerable, the inhaled

The Journal Lancet

low-silica dust may have no significant effect in localizing
the infection. In that event the tuberculosis will develop
exactly as though no dust were being inhaled.

With the third possibility for mode of onset, in which
silicosis develops in lungs with old and well healed tuber-
culous scars, there is the same tendency for the silica
particles to accumulate in excessive amounts around the
scars. However, since the obsolete scars are no longer
stimulating the development of more fibrous tissue, only
silicotic nodules develop in such areas. The fibrosis there-
fore becomes massive only when the individual nodules
begin to conglomerate by encroachment on one another.
Such conglomerate fibrosis is never as massive as when
the tuberculous infection is also laying down fibrosis,
although it may become quite dense when the silica in-
halation is excessive. The author has seen several such
cases develop, in which there was also a compensatory
emphysema below the dense fibrotic lesions. Because the
tuberculous scars are sterile, there is no sequestered tuber-
culous infection, and hence no progressive silico-tubercu-
losis results.

It has been argued by some, notably the Sea View
Hospital investigators, that such fibrotic lesions should
not be referred to as "silico-tuberculosis” because of the
absence of tuberculous disease. They believe that this
condition should be called "third-stage silicosis” or "mass-
ive conglomerate silicosis,” because silicotic fibrosis is the
only pathological tissue involved, except for the calcified
tuberculous scars. These scars, they believe, have no
connection whatever with the type of fibrosis that results.

There is reason to believe, however, that the scars
were a factor in the excessive localization of silica, since
classical silicosis, in the absence of previously damaged
areas of the lung, develops as a more or less uniform dis-
tribution of nodules throughout both lungs. Interfer-
ence with lymphatic flow in the region of the scars ap-
pears to be a logical explanation for the excessive deposit
of silica around such damaged areas. It has been sug-
gested that the term "tuberculo-silicosis” may be prop-
erly applied to such lesions, because it gives recognition
to the probable mode of onset and still emphasizes that
the lesion is primarily silicosis.

The fourth possible combination of silicosis and tuber-
culosis is one in which the lungs are invaded by tubercle
bacilli after a nodular silicosis has already developed. If
the number of bacilli in the invasion are relatively few,
they may localize exactly as they would in a nonsilicotic
lung, in the upper lobes with a reinfection infiltration
or anywhere in the lung if the infiltration is primary.
The resulting lesion may be no different than in a non-
silicotic lung if the bacilli are not localized adjacent to
silicotic tissue. However, if silica inhalation continues
after the invasion of the tubercle bacilli a chronic silico-
tuberculous lesion may result, exactly as described above.
Occasionally the rapidly progressive perinodular type of
silico-tuberculosis results, owing, possibly, to overwhelm-
ing invasions of bacilli. Tuberculous granulation tissue
seems to develop on the surface of the silicotic nodules,
and a relatively rapid multiplication of bacilli and spread
of the infection result. Such cases are relatively un-
common, however, probably because few workers have

developed a nodular silicosis before age 50 and primary
or first reinfection infiltrations of tubercle bacilli are
rare after age 50.

SYMPTOIVyVTOLOGY

The typical case of chronic silico-tuberculosis often
remains entirely free from symptoms for many years,
except for varying degrees of dyspnea, depending on the
extent of the dense fibrosis and the resulting compensa-
tory emphysema. Small areas of conglomerate fibrosis,
however, may be no more disabling than a discrete nod-
ular silicosis, which does not usually cause any signifi-
cant dyspnea until it is well advanced. At what point
dyspnea becomes manifest in the development of a silico-
tuberculosis varies considerably with different individuals,
and depends largely on the coexistent development of
emphysema, as well as on the status of the cardiovascular-
renal system. If the associated emphysema was due to
causes other than the developing silico-tuberculosis, and
was already present when the latter developed, as with
a long-standing asthma, dyspnea may become severe rela-
tively early. The same is true for a pre-existing heart
disease or a progressive arteriosclerotic heart disease. In
evaluating the disability of a well developed case of
silico-tuberculosis for medico-legal purposes, these other
causes of dyspnea must be considered along with the
lung pathology. At times the dissociation of the non-
occupational causes from the occupational is most dif-
ficult.

The symptoms and signs of active tuberculosis may
be absent for many years. When the cough becomes
productive and loss of weight is apparent we may sus-
pect that tubercle bacilli have made their way to the sur-
face of the chronic lesion, where their multiplcation and
eventual spread occur.

Diagnosis

When a worker who gives a history of significant
silica exposure is found to have a massive fibrotic lesion,
as seen on his chest X-ray film, the usual follow-up tests
are indicated to determine whether tubercle bacilli are
being liberated into the bronchial tree. Repeated sputum
tests are necessary, and several gastric analyses are ad-
visable if the sputum remains negative. It is often help-
ful to determine whether a cavity is present in the cen-
ter of the dense fibrosis, by means of an overpenetrated
or Bucky film. The presence of a significant cavity
usually, but not always, means an active focus of tuber-
culosis. In the absence of any tuberculous tissue, ex-
tremely dense fibrotic areas may occasionally become
necrotic, owing to deprivation of blood supply. Such
nontuberculous or ischemic cavities are not uncommon,
but usually do not attain any great size.

A blood sedimentation test may be helpful in the dif-
ferential diagnosis. A normal sedimentation rate usually
indicates that the fibrotic lesion is not harboring necrotic
tuberculous tissue. However, this result does not rule
out a dormant tuberculous infection, which makes this
test most useful for periodic observations of such a case.
When a previously normal sedimentation rate suddenly
increases, one must be suspicious of a threatening break-
through and spread of the infection, even though no
change has been observed on the periodic chest films.

April, 1946

A tuberculin test is not as helpful as one might ex-
pect in differentiating the infected and noninfected case.
The tuberculo-allergy has been observed to become defi-
nitely depressed in cases where the fibrotic wall around
a silico-tuberculous lesion is extremely dense, doubtless
because of the decreased absorption of toxic material
from the infected area. However, reactions are usually
obtained with larger doses of tuberculin, and this test
is recommended as a routine procedure when there is
doubt about the presence of an associated tuberculosis
in a case of conglomerate silicosis.

Even when all clinical and laboratory signs indicate
an absence of active tuberculous disease, it is not safe
to conclude that one is dealing with a nontuberculous
conglomerate silicosis. In some cases only by periodic
observations for evidence of spread of infection is it
possible to differentiate the infected from the non-
infected. In some instances the tuberculous disease is
so completely isolated that some pathologically active
cases escape detection until the post-mortem studies are
made. From a practical point of view it is safer to
assume that a dense fibrotic lesion is infected, for then
the affected worker is offered more frequent observa-
tions. Too often in such cases the worker has been
assured that the disease is pure silicosis, only to be dis-
covered later with far advanced open tuberculosis. In
the meantime he may have disseminated countless num-
bers of bacilli in his daily contacts, owing to carelessness
that might have been avoided had he been warned that
he might in future develop an open tuberculous lesion.

Management of Cases

A true understanding of the relationship of silicosis
and tuberculosis is of great practical importance to all
physicians dealing with these problems. It is not enough
to determine the current clinical inactivity of a silico-
tuberculous lesion and then dismiss the patient. Each
case must be carefully analyzed and evaluated. The
physician must attempt to ascertain the rate of develop-
ment of the present pathology (by consulting previous
films if available) ; to determine the exact silicosis hazard
of the worker’s job; and to predict the future course
of the lung pathology.

Obviously, if the worker’s job involves considerable
silica exposure a shift to a dust-free or silica-free job
is advisable, unless adequate protection from further
silica inhalation can be given. An estimate of present
disability, if any, must also be made, so that the work
will not be too great a strain physically.

Since disabling silicosis or silico-tuberculosis is com-
pensable in states that have occupational disease laws,
compensation is due such a worker when he is no longer
able to carry on with his regular job or a similar one
because of the lung pathology. Before he is advised to
discontinue his work altogether, a very careful analysis
of all associated factors is necessary, including an evalua-
tion of his possible mental reaction to complete dissocia-
tion from his life’s work. In most cases it is better to
keep these clinically inactive employees at their regular

occupations if possible, or to shift them to more seden-
tary and less dusty jobs for the same employer. Such
a course necessitates frequent periodic observations, in
order to detect the development of clinical activity of
the tuberculosis as early as possible.

The management of the case with threatening develop-
ment of clinical activity is often very difficult. At what
point to advise that work be discontinued and sanatorium
care started cannot be defined accurately. In general
the determining factor must be the type and extent of
the lung pathology. If there is definite hope of arrest-
ing the progress of a spreading infection by sanatorium
care, then every effort should be made to convince the
affected worker that he will be benefited by quitting his
work and starting treatment.

On the other hand, if the silico-tuberculous fibrosis is
extensive and little hope can be held out for stopping its
continued progress, the worker should be kept on a
sedentary and dust-free job and examined frequently for
evidence of clinical activity. No one wishes to deprive
a wage earner of his job when there is doubt that bed
rest and other modern methods of treatment will be
at all effective in altering the future course of the dis-
ease. These decisions require all the clinical acumen and
intelligent handling that can be mustered, and each case
must be dealt with individually.

It seems too obvious to mention at all that clinically
active cases with tubercle bacilli in their sputum must
be removed from their work as soon as discovered and
placed in a sanatorium if possible. Yet everyone dealing
with these problems has met with cases where the infect-
ed wage earner flatly refuses to leave his work. Such
cases must be turned over to the public health authori-
ties for disposition. Where the public health regulations
are lax and the laws have no teeth in them, these cases
sometimes become a most difficult problem. Usually,
however, a clear-cut explanation of the situation suffices,
particularly when the wage earner is assured that he will
be given a job after the disease is arrested.

While it is generally agreed that the treatment of
active silico-tuberculosis is not too effective or satisfac-
tory, occasional cases have shown surprising results.
Where the silicosis is early and the tuberculous lesion
relatively recent, even collapse therapy has been effective
in some cases.

The author has under observation a number of sili-
cotic foundry workers who made a satisfactory arrest
of their tuberculosis and who are working daily in de-
partments where they no longer are exposed to dust and
where the work is not too arduous. Experience has shown
that it is safer to offer an optimistic prognosis and at-
tempt treatment, even when the chances of obtaining a
favorable result do not appear too bright. With a true
understanding of the relationship between silicosis and
tuberculosis, and with close medical supervision and in-
telligent handling of cases when they arise, at least some
of these unfortunate individuals may be rehabilitated
to a useful life.

100

The Journal Lancet

Histoplasmin Skin Sensitivity and Pulmonary

Calcifications

A Revieiv

Herbert L. Mantz, M.D.

Kansas City, Missouri

Calcium deposits in the lungs are the end result of
necrotizing lesions. They are to be found in the
parenchyma, the pleura, and especially in the lymph
nodes of the lung and the mediastinum. The tubercle
bacillus has been considered the most common necrotiz-
ing agent, and with few exceptions calcium deposits
found in the pulmonary structures have been attributed
to tuberculous infection.

Because of the work of Myers, Hetherington, Mc-
Phedran, and many others the tuberculin test came to
the number one position as a case finding weapon. The
reliability of this test was hardly questioned until a few
years ago, when, as X-ray studies became more numer-
ous, films were made of nonreactors as well as reactors,
and the efficiency of the tuberculin test was questioned.

It is necessary to mention only a few of these tuber-
culin-X-ray studies. Nelson, Mitchel, and Brown 11
found many patients with manifest calcium deposits to
be nonreactors to tuberculin. Crimm and Short,2,3 in
a series of 1384 nonreactors, found 191 to have calcium
deposits. The most striking surveys were made in Ten-
nessee, where Gass and his co-workers s found 39.4 per
cent of tuberculin reactors and 46.2 per cent of non-
reactors to have calcium deposits.

Such reports were so positive and conclusive that some
workers accepted the findings and concluded that in
many persons there is an early loss of sensitivity to tuber-
culin. Dearing/’ from the results of his study in which
he found 35.4 per cent calcium in tuberculin reactors
and 34.2 per cent in nonreactors, concluded that the
single dose Mantoux testing is reasonably efficient, but
the X-ray is the basic tool in case finding.

In this controversy the tuberculin test had its follow-
ers. The test was found to be positive in almost all cases
in which a definite diagnosis of tuberculosis could be
made, i.e., by the demonstration of tubercle bacilli.
Douglas 6 and his group in Detroit found the test effi-
cient in practical case finding. Furculow et al 7 in their
studies found that the tuberculin test was very reliable
and that very few active cases of the disease would be
missed by the use of a relatively small dose of tuber-
culin. Dahlstrom 7 reported that most cases positive to
low doses of tuberculin did not lose their sensitivity.

We can sum up these studies as follows: Reliable

reports show that almost all cases of tuberculosis react
to tuberculin. A large number of young people who
have calcifications fail to react to tuberculin. Thus the
question arose as to whether the lesions producing cal-
cium in nonreactors were tuberculous.

In 1939 Long !* stated: "However, there is still room
to doubt that all of the lesions commonly diagnosed as

calcified nodules of primary tuberculosis are really tuber-
culous. In a community where calcifications are present
in half of the adolescent population, it is pertinent to
inquire if there could be any other cause than tubercu-
losis for the calcifications.”

Several studies have sought causes for calcifications
other than tuberculosis. Aronson et al.,1 who tested a
group of Indians with tuberculin and coccidioidin, con-
cluded that coccidioidomycosis was a common source of
calcifications in the area in which it was endemic. If
this disease produced calcium in the Southwest, why
could not it, or some other fungus, produce the calcifi-
cations found in the midwestern area? Some tests with
coccidioidin have been made in the Midwest, and from
them it appears extremely unlikely that coccidioidomy-
cosis is a source of calcium in this area.

The study of minimal tuberculous lesions in nurses
gave Carroll Palmer an opportunity to attempt an answer
to this question. This study has been in progress over
three years, and approximately ten thousand nurses in
65 schools located in widely separated metropolitan cen-
ters have been under close observation. Tuberculin tests
and 14 x 17-inch X-ray films of all students, both tuber-
culin reactors and nonreactors, were made at six-month
intervals. The tuberculin used was PPD, and the dose
was 0.0001 mg. Reactions with induration or edema
measuring 5 mm. or more in diameter 48 hours after
infection were considered positive. The results of this
study bring out the geographical difference in calcium
deposition and also demonstrate that this calcium does
not correspond to the incidence of tuberculosis infec-
tion.13

To demonstrate further the difference in calcium de-
posits and tuberculin sensitivity, the results in Kansas
City and Minneapolis are shown. In approximately equal
numbers of nurses the percentages of tuberculin reactors
are almost identical. However, the percentage with cal-
cium deposits in Kansas City is over ten times as great.
There must be something besides tuberculosis to produce
this difference.

Smith 14 had stated that this area of high calcification
in tuberculin-negative persons was the endemic area of
histoplasmosis. Christie,12 who had made some studies
in Tennessee, thought that histoplasmosis or a similar
closely related infection, which may be the cause of pul-
monary calcifications, is common in this locality.

With these leads, Palmer tested nurses in Detroit,
Minneapolis, St. Paul, Columbus, the two Kansas Cities,
New Orleans, Philadelphia, and Baltimore, with the re-
sults shown in Table 1.

April, 1946

101

Table 1

Showing Pulmonary Calcifications among Histoplasmin
and Tuberculin Reactors

City

Histo-

plasmin

Reactors

Pulmonary

Calcifica-

tions

Tuberculin

Reactors

Number

Tested

Kansas City, Missouri

65.8

23.7

14.2

646

Columbus

59.9

19.3

14.1

700

Kansas City, Kansas ...

54.0

20.7

18.8

213

Baltimore

.. 27.0

10.9

17.8

926

New Orleans

26.1

6.4

16.3

498

Detroit

14.4

7.4

15.1

623

Philadelphia

14.0

7.1

20.9

772

Minneapolis

6.4

2.4

12.0

1018

These data do not represent a true geographical dis-
tribution, because though most students attend schools
close to their homes, some come from other areas.

The most striking evidence comes from a study of the
nurses with pulmonary calcifications. Of 5396 nurses
tested, 590 had demonstrable calcific deposits. Table 2
shows the number and percentage of tuberculin and
histoplasmin reactions among nurses having pulmonary
calcifications.

Table 2

Tuberculin and Histoplasmin Reactions among Nurses
Having Pulmonary Calcifications

Percent-

age

Number

Tuberculin positive— Histoplasmin positive

14.1

Tuberculin positive— Histoplasmin doubtlul

2.1

Tuberculin positive-Histoplasmin negative

9.2

Subtotal (all tuberculin positive)

. 25.3

149

Tuberculin negative— Histoplasmin positive

66.8

394

Tuberculin negative— Histoplasmin doubtlul

2.2

Tuberculin negative— Histoplasmin negative

5.8

Subtotal (all tuberculin negative)

.. 74.7

441

Total

100.0

590

Among those having calcium a much higher propor-
tion reacted to histoplasmin than to tuberculin. In fact,
9.2 per cent reacted only to tuberculin and 66.8 per
cent reacted only to histoplasmin. These data exclude
doubtful reactors. Given a case of calcium in this area,
it is more likely to react to histoplasmin than to tuber-
culin. Especially interesting is the small number with
calcium who were nonreactors to both tuberculin and his-
toplasmin. This number becomes more significant when
we consider the numbers tested, as shown in Table 3.

Table 3

Percentage and Number of Student Nurses Having Pulmonary
Calcifications according to Tuberculin and
Histoplasmin Reactions

Percentage

with cal-

Numbei

Skin reactions

cifications

tested

Tuberculin

positive-Histoplasmin

positive

34.5

275

Tuberculin

positive-Histoplasmin

negative

10.2

528

Tuberculin

negative— Histoplasmin

positive

30.9

1317

Tuberculin

negative— Histoplasmin

negative

1.0

3276

Only 1 per cent of 3276 nurses negative to both tests
had calcium. This percentage is statistically rather in-
significant and could be accounted for by many variables.
Apparently histoplasmin and tuberculin skin reactions
will screen out almost all persons in this area who have
pulmonary calcifications.

Histoplasmosis, or infection with Histoplasma capsu-
latum, was first described by Darling in 1906. Two ex-
cellent discussions of the disease in recent literature are
found in "Histoplasmosis in Man,” by Parsons and
Zarafonetis (Archives of Internal Medicine, January
1945) and in Manual of Clinical Mycology , by Conant
et al. (Saunders, 1945).

The disease occurs at all ages. It attacks the reticulo-
endothelial system primarily, and pulmonary lesions are
common. The diseases to be differentiated most fre-
quently are tuberculosis, Hodgkin’s disease, aleukemic
lukemia, and malignant neoplasm. Successful ante-
mortem diagnosis has been most frequently provided by
histologic examinations of biopsy material. Cultures
from blood and biopsy material have been successful in
several instances. It is necessary for cultures to grow
a considerable length of time, i.e., two to four weeks.
The yeast or parasitic form is the one found. On cul-
ture it will revert to the mycelial form, but on proper
culture the yeast form can be maintained. Some cases
of the disease have terminated fatally.

The history of coccidioidomycosis, and, for that mat-
ter, of tuberculosis, reminds us that at one time these
diseases were considered almost universally fatal. Fur-
ther studies showed that there was practically universal
infection in the endemic areas, but that the proportion
of death to infection was relatively low. Smith 14 states
that not over one in 500 to 1000 cases of coccidioido-
mycosis becomes disseminated.

By analogy with these two diseases it is not too unrea-
sonable to postulate that histoplasmosis may be a similar
infection, with a widespread mild primary phase and only
an occasional fatal progressive termination. If this dis-
ease does occur in a subclinical form it becomes neces-
sary to know how infection occurs, the nature of the
precalcific lesion, and the usual course. Studies intended
to clarify these points are now in progress.

Before any histoplasmin tests were done, routine X-rays
were made of 2500 Kansas City school children. Three
months later histoplasmin and tuberculin (PPD) tests
were made on a considerable number of this group. The
results of this study are shown in Table 4.

Table 4

Histoplasmin and Tuberculin Reactions and Calcifications
in 2500 Kansas City School Children

Tuberculin

Histoplasmir

i Calcifi-

reactors

cations

(Per Cent)

Kindergarten children

White

3.5

Colored

6.5

—

Junior high school

White

Colored

—

Senior high school

—

102

The Journal Lancet

This is a rather rough estimation. At present a more
extensive survey, including some 15,000 school children,
is under way. From this study more information should
be obtained.

From the number tested and inspected by X-ray to
date many have been selected for follow-up. There are
many with soft parenchymal shadows and hilar node
involvement who do not react to tuberculin. These have
much the appearance of primary tuberculosis lesions.
Such cases are being followed with serial films. A lab-
oratory has been set up for pathological and bacterio-
logical studies. We have every reason to believe that the
stage of calcification is the end result of this disease,
and if the organism is to be demonstrated it will be
found at the time soft lesions are seen. These cases are
apparently asymptomatic, or the symptoms and signs
are such that they have been attributed to some of the
many common childhood infections.

The work to date rests solely on the acceptance of
the specificity of the histoplasmin reaction, for which
indirect evidence has been obtained. With this evidence
Palmer 12 concluded:

1. That mild, probably subclinical, infection with His-
toplasma capsulatum (or an immunologically related or-
ganism) is widely prevalent in certain states and rela-
tively infrequent in others.

2. That, in general, those states in which the fre-
quency of reactions to histoplasmin is high are those in
which pulmonary calcifications are also high.

3. That a very high proportion of the pulmonary cal-
cifications observed in roentgenograms of tuberculin-
negative persons are due, not to tuberculosis, but prob-
ably to histoplasmosis.

We may conclude from the present evidence that the
tuberculin test is a more accurate index of tuberculous
infection than the X-ray film, thus reversing often ex-
pressed ideas.

References

1. Aronson, J. D., and others: Relationship of Coccidioido-
mycosis to Calcified Pulmonary Nodules. Arch. Path., 34: 31,
1942.

2. Crimm, Paul D., and others: Tuberculin Tests and Roent-
genograms. Am. Rev. Tuberc., 42: 203, 1940.

3. Crimm, Paul D., and Short, Darwin M.: Tuberculin An-
ergy in Cases with Pulmonary Calcifications. Am. Rev. Tuberc.,
39:64, 1939.

4. Dahlstrom, A. W.: The Instability of the Tuberculin Re-
action. Am. Rev. Tuberc., 42: 471, 1940.

5. Dearing, Palmer: Tuberculin and X-ray Survey. Am.

Rev. Tuberc., 40: 640, 1939.

6. Douglas, Bruce: X-ray Findings in Tuberculin Reactors
and Nonreactors. Am. Rev. Tuberc., 40: 621, 1939.

7. Furculow, Michael N., and others: Quantitative Studies

of the Tuberculin Reaction. Public Health Repts., 56: 1 082 —
1 100, 1941.

8. Gass, R. S., Gauld, R. L., Harrison, E. F., Stewart, H. C.,
and Williams, W. C.: Tuberculosis Studies in Tennessee. Am.
Rev. Tuberc., 38: 441, 1938.

9. Long, Esmond R.: Editorial. Am. Rev. Tuberc., 40: 607,
1939.

10. Long, E. R., and Stearns, W. H.: Physical Examination
at Induction. Radiology, 41: 144, 1943.

11. Nelson, Waldo E., Mitchell, A. Graeme, and Brown,
Estelle: The Intra Cutaneous Tuberculin Reaction Associated
with Calcified Intra Thoracic Lesions. Am. Rev. Tuberc.,
37: 311, 1938.

12. Palmer, Carroll E.: Nontuberculous Pulmonary Calcifica-
tion and Sensitivity to Histoplasmin. Public Health Repts.,
60: 513, 1945.

13. Palmer, Carroll E., and Furculow, Michael N.: Unpub-
lished charts and reports.

14. Smith, E. C.: Coccidioidomycosis. M. Clin. North Amer-
ica, 27, 790, 1943.

15. Zwerling, Henry B.: Unpublished report.

PENICILLIN SUPPLY MAY BE DOUBLED BY DEVELOPMENT
OF NEW STRAIN OF MOLD

Research workers at the University of Wisconsin have developed a new strain of mold
which opens the possibility of doubling the nation’s supply of penicillin. The feat was accom-
plished by two botanists, Myron P. Backus and John F. Stauffer, who exposed the spores
of the penicillin-producing mold to powerful ultraviolet rays. Such rays cause changes, un-
predictable and incompletely understood, in the genes of spores and seeds, with resultant
changes in the characteristics of the plants or fungi springing from them.

The new strain, known as Q176, has not been patented, and soil cultures of it are
therefore being supplied gratis on request to penicillin manufacturers in this country and in
England, France, China, and other countries, and many are already using it in their fermen-
tation tanks.

The news is of special importance in view of the fact that demand for penicillin has
increased far beyond the enormous production built up in the last three years by American
scientists and drug manufacturers. Because of the acute shortage penicillin was recently
returned to an allocation basis by the government.

American production in December 1945 was 700 billion units, or something over 1000
pounds of the powdered sodium form of the pure chemical, but it was still short of demand
for human use in this country by at least 100 billion units. Demand also is rising rapidly
for veterinary use in the United States, while the need of the rest of the world is just
beginning to manifest itself. Wisconsin’s Q176 is considered to be a major step forward in
bringing supply into line with the increasing need.

The hunt for a still more efficient penicillin producer is still on, despite the possibility
that chemical synthesis of penicillin might render the world free of dependence on natural
production.

April, 1946

103

Tuberculosis Control Depends Upon the Practicing

Physician

L. L. Collins, M.D.

Ottawa, Illinois

Although there has been for nearly one hundred fifty
l years a very effective means of preventing smallpox
and for nearly fifty years an effective means of prevent-
ing diphtheria, neither of these diseases has been eradi-
cated. However, both diseases are under control, if by
control we mean low morbidity and mortality rates.

These diseases were brought under control only after
the practicing physician became interested and actually
participated in the immunization programs, as is evi-
denced by the fact that there are many people today
who refuse to be immunized or to have their children
immunized against these diseases because the type of
doctor to whom they go advises against it.

The success or failure of a health program depends
largely upon the attitude of the practicing physician
toward it. No health program can succeed if it is op-
posed by him, and its success is assured if he co-operates
and participates in it.

We possess all the knowledge we need to control tuber-
culosis. It has long been recognized that it could be con-
trolled if all cases were found while in the minimal or
early stage. The national, state, and county tuberculosis
associations have emphasized the importance of early
diagnosis and have conducted special early diagnosis
campaigns since 1928.

Various procedures for obtaining an early diagnosis
have been advocated. They include radio talks, movies,
posters, pamphlets, talks to civic groups, tuberculin test-
ing surveys, and, more recently, mass X-ray surveys.
All these procedures, or combinations of them, have
been found disappointing unless the practicing physician
co-operated and participated. The high percentage of
cases of advanced tuberculosis still being discovered is
evidence of this failure.

This fact has been recognized by many leaders in
tuberculosis work.

Dr. Edward Livingston Trudeau, in an address to the
National Tuberculosis Association in 1905, stated:
"Early detection of the disease is the first requisite for
success in its treatment. On the general practitioner and
the dispensary physician rests the great responsibility of
detecting the disease in its incipiency, for it is to them
and not the specialist that the patient first applies.”

Dr. J. A. Myers wrote in 1926: "There is no part of
tuberculosis work that has been so overlooked as that
carried on in the physician’s office. Here is where the
bulk of diagnostic work has always been done and where
it must continue to be done.”

Dr. Osier said, in a last word message to the general
practitioner on the subject of tuberculosis, "The leader-

Remarks as retiring president of the Mississippi Valley Tru-
deau Society at the annual banquet, October 9, 1945, held at
the Edgewater Beach Hotel, Chicago.

ship of the battle against this scourge is in your hands.”

Dr. Albert Daniels of California reported in 1938:
"Thirty per cent of the population consult some doctor
for some complaint during the year. If all private physi-
cians would be on the alert for tuberculosis a complete
survey of the population would be made every three
years. This policy would result in the finding of the ma-
jority of tuberculosis cases while the disease was still in
the early stages.”

Studies made at the Chicago Municipal Tuberculosis
Sanitarium and by Dr. Douglas of Detroit revealed that
65 to 70 per cent of the persons newly diagnosed as
having tuberculosis were first seen by the private physi-
cian. In smaller communities, without the excellent facili-
ties and the highly trained personnel for diagnosing
tuberculosis that these cities have, the percentage of cases
diagnosed by the private physician is much greater.

The control of tuberculosis depends on finding cases
while they are still in the early stages, and it is evident
that to do so we must have the co-operation of prac-
ticing physicians.

Experience in Detroit proved this beyond question.
When special emphasis was made upon getting the par-
ticipation of the practicing physician, the percentage of
minimal cases diagnosed increased from 17 to 27 within
the first year, and the death rate decreased 11.4 per
hundred thousand. When the program was discontinued
the percentage of minimal cases diagnosed promptly
decreased.

Our own experience also indicates what can be ex-
pected from a program in which the practicing physi-
cian participates. On January 1, 1938, a program to
control tuberculosis was started in De Kalb County,
which has a population of 35,000. The importance of
the interest and co-operation of practicing physicians
for the success of the program was fully appreciated,
and their participation was enlisted. All the doctors par-
ticipated in the surveys made throughout the county.

Tuberculin was furnished the doctors, and they were
urged to test all their patients and to make X-ray in-
spections of the chests of all reactors. Clinics were set
up at the sanatorium as a consultation service to the
doctors. No patient was accepted except at the request
of the practicing physicians, and a report on each ex-
amination made at the clinic was sent to the doctor
referring the case. X-ray film and fluoroscopic inspec-
tions and laboratory work were free to both doctor and
patient.

This type of program has had excellent results. The
co-operation and participation of the practicing physi-
cians are excellent. The effectiveness of this kind of
program can be judged by the results.

104

The Journal Lancet

The percentage of minimal cases discovered each year
has varied between 45 and 70 per cent. The number of
deaths from tuberculosis decreased from an average of
15 per year to two in 1940, two years after inaugura-
tion of the program. In no year since 1940 have deaths
exceeded three.

There are now 1 1 patients under treatment at the
sanatorium. There is only one patient in the county with
a diagnosis of active tuberculosis who is not in the sana-
torium. His sputum is negative and he co-operates fully
with the clinic. The percentage of tuberculin reactors in
the high school groups has steadily decreased.

In September 1938 a similar program was introduced
in La Salle County, which has a population of 100,000.
Here the co-operation and participation of the doctors
are equally good, and the results obtained are just as
encouraging. The percentage of minimal cases discov-
ered each year has varied between 37 and 50 per cent.
Deaths from tuberculosis dropped from 48 in 1938 to
10 in 1942, and in the past three years there has been
an average of 12 deaths from pulmonary tuberculosis
per year. The incidence of active tuberculosis has like-
wise decreased. As of October 1, 1945, we had 32 pa-
tients in the sanatorium under treatment and three pa-
tients under treatment elsewhere. There are six patients
with known active tuberculosis who refuse sanatorium
care.

In two high schools in La Salle County, each with an
enrollment of approximately one thousand students, one
school had 94 per cent and the other 98 per cent of
the students examined for tuberculosis last year.

The co-operation of the doctor assures the co-opera-
tion of the public.

A most important phase of our program is the use
we make of the tuberculin test. It was interesting to
note that the doctors did not become interested in the
program, nor did they tuberculin test their private pa-
tients, until they had experience of tuberculin testing
in a survey. There is a very small group of doctors in
La Salle County who have not had an opportunity to
participate in a tuberculin testing program. Some of
these doctors have had the experience of treating a
patient for a considerable period of time before it was
discovered that the patient had far advanced pulmonary
tuberculosis. No doctor has had this embarrassing ex-
perience after he has participated in a tuberculin testing
survey.

Tuberculin testing in a survey makes the doctor tuber-

culosis minded. A tuberculosis-minded doctor does not
overlook a case of active tuberculosis. In our program
the use of the tuberculin test was the most effective
factor in obtaining the co-operation and participation of
the practicing physician. The educational value of the
tuberculin test to both patient and doctor cannot be
overemphasized. The greater the number of practicing
physicians instructed in the use and value of the tuber-
culin test, the greater will be the number of people
tuberculin tested, and the more tuberculosis minded will
be both the physician and the people of the community.
And a community in which the practicing physician and
the people are tuberculosis minded will soon have tuber-
culosis under control, for examinations for tuberculosis
will be made on a larger scale and a high percentage of
new cases will be discovered in the early stages.

The tuberculin test should be a part of these exam-
inations, for otherwise a diagnosis of tuberculosis is sure
to be made in error. Such an error is not only unfair
to the patient; it will also react unfavorably toward the
tuberculosis program. Of the 159 Army rejectees for
tuberculosis I examined in the three counties, 46 were
found to be nonreactors to tuberculin. Subsequent ex-
aminations established that these men did not have
tuberculosis. A simple tuberculin test would have avoided
this mistake.

These cases illustrate the importance of the tuberculin
test as a diagnostic aid and demonstrate the errors that
will occur if the diagnosis is made from an X-ray film
alone.

Tuberculosis surveys offer a splendid opportunity to
acquaint physicians with the technique and value of the
tuberculin test. People who have found that they react
to tuberculin usually become interested in tuberculosis
control measures.

In conclusion: Tuberculosis can be controlled with our
present-day knowledge, and the success of our control
programs will be in direct proportion to the co-operation
and participation of the practicing physician. It is fit-
ting that I close these remarks by referring again to the
teachings of such leaders in tuberculosis work as Dr.
Trudeau, Dr. Osier, Dr. Myers, and others, who for
many years have affirmed that tuberculosis control de-
pends upon the practicing physician.

Tuberculosis — a pandemic, infectious disease that claimed 55,000 lives in 1944 — com-
mands the immediate attention of all the people of this country. Its eradication will lag just
in proportion to the ignorance, carelessness, and apathy of the population. The fact that the
death rate was only one fifth of that prevailing fifty years ago is scant cause for complacency
in the light of that needless toll of wasted lives. The further consideration that there are
at least 500,000 actual or potential spreaders of infection scattered throughout the country
is still less reassuring. The menace is not lessened by the fact that the major portion of
these are either unrecognized or under insufficient observation. — Kendall Emerson, M.D.

April, 1946

105

Facts and Inferences of Minnesota Sanatorium

Admittances

Edwin J. Simons, M.D.

Swanville, Minnesota

With the anti-tuberculosis campaign of the United
States Public Health Service in progress, with
mass radiography programs for the detection of tubercu-
losis in Minnesota being initiated and in various stages
of advancement, an analysis of sanatorium admittances
and other statistical data seemed warranted in order to
justify or refute the need for such intensified diagnostic
measures.

Owing equally to lack of time and the difficulty of
obtaining statistics for the years 1936 and 1937, this
analysis covers only eight years, 1938 to 1945, inclusive,
instead of ten years, as seemed preferable.

As shown in Table 1, both total admittances and first
admittances of reinfection cases are listed, but the sub-
divisions into minimal, moderately advanced, and far
advanced cases, and their respective percentages, apply
only to first admittances in both Tables 1 and 2. This
portion of the work and its interpretation, accordingly,
are based entirely upon first admittances to Minnesota
sanatoriums. By the term "reinfection cases” is meant
all "aduit or destructive pulmonary tuberculosis,” or all
pulmonary tuberculosis other than "childhood or first
infection pulmonary tuberculosis.”

Table 1 shows that total admittances of all reinfection
cases decreased from 1476 in 1938 to 1389 in 1945, a
decrease of 87 cases. During the same years total first
admittances of reinfection cases decreased 223 cases,
from 927 to 704. Since general trends over an eight-
year period are considered more significant, minor or
even major fluctuations occurring within the study period
are left to the reader’s interpretation. The yearly total
admittances of all reinfection cases during this period
averaged 1475, and the decrease of 87 cases from 1938
through 1945 represents only 6 per cent of this average.
Over the same period the yearly first admittances of
reinfection cases averaged 829, of which the 223 eight-
year decrease is 27 per cent. The marked decrease of
first admittances of reinfection cases in comparison with
total admittances of all reinfection cases may be sig-
nificant.

From the diagnostic and epidemiological point of
view, percentages of first admittances by classification
are important. In these columns (Table 1), it is seen
that from 1938 to 1945 minimal cases first admitted to
sanatoriums increased 2.47 per cent, from 11.87 to 14.34
per cent. This increase is neither progressive nor signifi-
cant, since there was a fluctuation of 7.87 per cent in the
years 1939 to 1942. It could be considered important
that from the high percentage of 18.58, in 1941, first
admittances of minimal cases decreased in 1945 to 14.34
per cent, which is less than the e-ight-year average of

From the Medical Unit of the Division of Social Welfare,
Globe Building, St. Paul, Minnesota.

14.95 per cent. However, in spite of fluctuations, both
major and minor, the percentage of first admittances of
minimal cases to Minnesota sanatoriums over the eight-
year study period cannot be considered to have changed
appreciably.

First admittances of moderately advanced cases have
increased in eight years from 29.66 per cent in 1938 to
35.94 per cent in 1945, or 6.28 per cent. The converse
is true of admittances of far advanced cases, which de-
creased from 58.47 per cent in 1938 to 49.72 per cent
in 1945, or 8.75 per cent.

Thus, it can be seen that fewer far advanced cases
were first admitted to Minnesota sanatoriums in 1945
than in 1938, and that more moderately advanced and
slightly more minimal cases were first admitted in 1945
than in 1938. This shift of 8.75 per cent, composed of
6.28 per cent moderately advanced and 2.47 per cent
of minimal cases, represents a trend in the right direc-
tion of early admittance. Nevertheless, the fact that
over the last eight years an average of 85 per cent of
first admittances to Minnesota sanatoriums have been
moderately and far advanced cases, while only 15 per
cent have been minimal cases, is not encouraging.

In order to determine any difference in urban and
rural factors, the data were divided into two groups.
The urban group consisted of the three sanatoriums
serving Hennepin, Ramsey, and St. Louis counties, in
each of which is located a city of the first class: Minne-
apolis, St. Paul, and Duluth, respectively. All other
sanatoriums of the state provided data for the rural
group. The statistics for each of the two groups are
seen in Table 2.

Table 2 shows that 13.4 per cent of first admittances
in urban sanatoriums are minimal cases, as compared
with 16.7 per cent in the rural areas — a difference of
3.3 per cent. The comparable percentages for far ad-
vanced cases are 52.5 in urban sanatoriums and 52.6 for
rural sanatoriums. In moderately advanced cases the
percentages are 34.1 for urban sanatoriums and 30.8 per
cent for rural sanatoriums. In general, then, the slight
advantage the rural sanatoriums have in early admit-
tances of minimal cases is balanced by a higher percent-
age of first admittances of moderately advanced cases.

Table 2 shows another trend that may be of impor-
tance. In urban sanatoriums total admittances of rein-
fection cases from 1938 through 1945 decreased 80,
while first admittances of reinfection cases decreased 85.
In contrast, in rural sanatoriums total admittances of
reinfection cases decreased only 7 over the eight-year
period, from 700 in 1938 to 693 in 1945, but total first
admittances decreased 140, from 420 in 1938 to 280 in
1945. It may be that variations from year to year in
both these tabular columns minimize the significance of
such a minimal variation as 7 cases.

106

The Journal Lancet

Table 1

First Admittances of Reinfection Cases to State Sanatorium and County Sanatoriums for the Years 1938-1945

Year

Total

Admittances
of all

Reinfection

Cases

Total

First

Admittances

Reinfection

Cases

Minimal

Sputum

Moderately Advanced
Sputum

Far Advanced
Sputum

Percentage of First Admittances
by Classification

Posi-

tive

Nega-

tive

Not

Done

Posi-

tive

Nega-

tive

Not

Done

Posi-

tive

Nega-

tive

Not

Done

Mini-

mal

Moderately

Advanced

Far

Advanced

1938

1476

927

-7

111

130

383

111

11.87

29.66

58.47

1939

1445

906

131

391

10.71

32.01

57.28

1940

1481

847

109

122

110

386

15.46

28.22

56.32

1941

1488

829

123

118

135

352

18.58

31.12

50.30

1942

1617

914

125

132

143

373

16.41

31.51

52.08

1943

1483

733

151

288

14.60

34.79

50.61

1944

1419

772

117

124

154

278

17.62

36.92

45.46

1945

1389

704

105

144

276

14.34

35.94

49.72

Totals an

d Averages. .

117

788

938

1061

144

2727

621

155

14.95

32.52

52.54

Range

1476 to 1389

927 to 704

Differ-

ence

223

Average

1475

829

However, it is noteworthy that first admittances of
minimal cases decreased in rural sanatoriums by 140
cases, or 37 per cent, over an eight-year period. Also,
as seen in Table 1, this decrease of 140 cases in rural
sanatoriums constitutes the greater part of the eight-
year decrease of 223 cases in first admittances of reinfec-
tion cases in all sanatoriums, and is greatly in excess of
the decrease of 83 cases in urban sanatoriums.

Several questions are immediately raised by these find-
ings, namely: Is there any relation between this 140-
case decrease of total first admittances and the eight-
year decrease in percentage of minimal cases first admit-
ted, or between this 140-case decrease and the appre-
ciable eight-year increase of moderately advanced first ad-
mittances, from 25.71 to 34.64 per cent? Further, are
fewer cases in rural districts being diagnosed, or are as
many cases being diagnosed but failing to enter sana-
toriums? Suffice it to say that this disproportionate 140-
case decrease of first admittances of reinfection cases in
rural sanatoriums does justify intensification of diag-
nostic and patient segregation programs in rural districts.

For further consideration of the problems presented
by first admittances to the sanatoriums of the state.
Table 3 was prepared by the Minnesota Department of
Health.1 From this table it is seen that, except for an
increase in 1943, the total yearly deaths from tubercu-
losis in Minnesota have steadily decreased over eight
years to an all-time low of 625 in 1945. During this
same period nonresident deaths from tuberculosis show
a gradual but irregular increase. The same trend is
shown in both the total annual death rate from tuber-
culosis and the rate exclusive of deaths of nonresidents.
Thus the trend in Minnesota is an encouraging one.

New cases exclusive of the primary phase, that is,
"reinfection cases,” as they are termed in Tables 1 and
2, are worthy of some consideration. Fluctuations from
year to year are seen to be both irregular and inconstant.
Yet 1801 cases in 1945 are 122 cases less than in 1938,
and 202 cases lower than the eight-year average, and
the 1945 figure represents an all-time low.

New cases reported per death numbered 2.88 in 1945,
while in 1938 only 2.36 cases were reported for each
death. While the 1945 ratio of 2.88 is not the highest
during the study period, it is the third highest and is
above the average 2.72 for the eight-year period. Both
these facts, the number of new cases per year and the

ratio of new cases per death, indicate that the total de-
crease of 223 cases of first admittances of reinfection
cases to all sanatoriums and the decrease of 140 cases
of first admittances of reinfection cases to rural sana-
toriums are consistent with actual case incidence in Min-
nesota, and do not imply faulty case finding or diagnosis.

One of the most deplorable features shown in Table 3
is the remaining high number and high percentage of
cases of tuberculosis first reported by death certificate.
It is true that the number of such cases has rather
steadily decreased from 166 in 1938 to 94 in 1945, that
94 is better than the eight-year average of 130, and that
it is also the lowest number of such cases reported in
any one year, and that, with one exception, the percent-
ages of cases first reported by death certificate show a
similar decrease. Nevertheless, these data indicate that
great improvement is needed in case finding and diag-
nosis.

Here, again, an attempt has been made to determine
whether the greater problem is an urban or a rural one
(Table 4).

Table 4 shows the cases first reported by death cer-
tificate in urban and rural areas. That the total number
of cases in the three larger counties shows a comparable
relation to population is apparent. The population of
the state is preponderantly rural, and accordingly more
cases of tuberculosis were first reported by death certifi-
cate in rural areas than in urban areas in each year ex-
cept 1941 and 1945. With the exception of one year,
1941, such cases have shown a steady decrease during
the eight years.

However, the number of such cases remains inordi-
nately high, i.e., 15 per cent (Table 3). It is true that
such cases may represent merely a failure to report them
before death as cases of tuberculosis. On the other hand,
the high total of them each year may present an impor-
tant diagnostic or epidemiological problem. Needless to
say, whichever factors are at work, concerted efforts
should be made to reduce the number of such cases.

From this analysis three facts appear to warrant in-
tensification of diagnostic and case finding methods:
(1) the low percentage of first admittance minimal
cases, (2) the decreasing number of first admittances
of reinfection cases, especially in rural districts, and (3)
the high number and percentage of tuberculosis cases
first reported by death certificate.

April, 1946

107

Table 2

First Admittances of Reinfection Cases to Urban and Rural Sanatoriums for the Years 1938-1945

Urban

Total

Admittances
of all

Reinfection

Cases

Total

First

Admittances

Reinfection

Cases

Minimal

Sputum

Moderately Advanced
Sputum

Far Advanced
Sputum

Percentage of First Admittances
by Classification

Posi-

tive

Nega-

tive

Not

Done

Posi-

tive

Nega-

tive

Not

Done

Posi-

tive

Nega-

tive

Not

Done

Mini-

mal

Moderately

Advanced

Far

Advanced

1938

776

507

101

199

9.67

32.94

57.39

1939

762

468

190

8.76

33.98

57.26

1940

728

441

184

12.47

32.43

55.10

1941

768

422

169

17.30

33.65

49.05

1942

808

496

199

12.30

32.46

55.24

1943

730

408

159

14.46

33.82

5 1 . 72

1944

741

445

108

159

17.53

36.63

45.84

1945

696

424

153

14.86

36.79

48.35

Totals and Averages

406

434

727

1412

429

13.4

34.1

52.5

Average

751

451

Range

776 to 696

507 to 424

Differ-

ence

Rural

1938

700

420

184

14.52

25.71

59.77

1939

683

438

201

12.78

29.91

57.31

1940

753

406

202

18.72

23.65

57.63

1941

720

407

183

19.90

28.50

51.60

1942

809

418

174

21.29

30.38

48.33

1943

753

325

129

14.77

36.00

49.23

1944

678

327

119

17.73

37.31

44.96

1945

693

280

123

13.57

34.64

51.79

Totals and Averages

382

504

334

1315

192

16.7

30.8

52.6

Average

723

378

Range

700 to 693

420 to 280

Differ-

ence

140

At this point the question arises: "What influence

has mass radiography upon early diagnosis of tubercu-
losis and early admittance of tuberculous patients to
sanatoriums?”

Experience in Ontario, as shown by Table 5 (Brink2),
provides the answer and emphasizes some features of
the present Minnesota analysis.

Table 5 shows that the percentage of minimal cases
admitted to Ontario sanatoriums prior to 1943 was 21,
whereas in Minnesota the eight-year average of minimal
cases among first admittances was 15 per cent. To in-
clude all admittances in the present study would de-
crease, rather than increase, the 15 per cent. It is evi-
dent that the percentage of moderately advanced cases
in Ontario, namely, 33, is almost the same as that in
Minnesota, i.e., 32.5 (Table 1). The improvement in
Canada lies in a marked decrease of admittances of far
advanced cases, that is, 44 per cent, as compared with
Minnesota’s 52.5 per cent.

The most important feature of Table 5 is the second
division, which shows that by use of mass radiography

these percentages have been reversed. That is, after
instituting mass radiography surveys, 57 per cent of
sanatorium admittances were minimal cases and only 13
per cent far advanced. These data show a marked im-
provement over the previous 21 pier cent admittances
of minimal and 44 per cent far advanced cases in
Ontario, and over the comparable figures of 15 per
cent and 52.5 per cent admittances of minimal and
far advanced cases in Minnesota.

In Minnesota mass radiography was pioneered by
Nopeming Sanatorium and its superintendent, Dr. G.
A. Hedberg. Recent data from him confirm Brink’s
experiences, as shown in Table 6.

Dr. Hedberg reported as follows on February 26,
1946: "On August 28, 1943, Nopeming Sanatorium
had 250 patients and 22 vacant beds. Today the sana-
torium has 271 patients and a waiting list of 43 defi-
nitely active cases of tuberculosis.” Thus it is evident
that in St. Louis County — where 72,433 persons were
studied by mass radiography during the period from
September 1943 through August 1945 — this method

Table 3

Number of Deaths, Death Rate per 100,000 Population, and Number of New Case Reports, 1938-1945

Cases First Reported

Deaths

Death Rate

New Cases

by Death Certificate

Year

(Exclusive of

per

Non-

Exclusive of

Primary

Death

Total Deaths

Total

resident

Total

Nonresident

Phase)

Number

(Per Cent)

1938

816

29.7

28.5

1923

2.36

166

1939

807

29.1

27.4

2009

2.49

144

1940

762

27.3

25.7

2111

2.78

143

1941

754

27.0

25.3

1863

2.47

117

1942

705

26.3

24.7

2190

3.11

138

1943

753

29.6

26.6

1951

2.59

128

1944

699

27.5

25.9

2172

3.10

109

1945

625

24.6

22.7

1801

2.88

Average

2003

2.72

130

108

The Journal Lancet

Table 4

Tuberculosis Cases First Reported by Death Certificate
in Hennepin, Ramsey, and St. Louis Counties
and in the Rural Counties, 1938-1945

Population

1938

1939

1940

1941

1942

1943

1944

1945

Hennepin
County

568,899

Ramsey
County

309,935

St. Louis
County

206,917

Total Urban
Cases

1,085,751

Total Rural
Cases

1,706,549

Total . .

2,792,300

166

144

143

117

138

128

109

brought to light a high percentage of minimal cases of
tuberculosis and converted sanatorium vacancies into a
waiting list.

Confirmation of this experience is seen in the result
of the Red Lake Indian survey 4 conducted by the Min-
nesota Department of Health and the Minnesota State
Sanatorium. In this survey, carried out in October 1945,
1500 persons submitted to thoracic X-ray study, and
27 new active cases were revealed in this Indian popu-
lation. As a result of this survey all vacant beds in the
Indian Building at the State Sanatorium were filled and
it became necessary to place some Indian patients in
beds for white patients.

Table 5

Influence of Mass Radiography upon Early Diagnosis
and Early Admittance to Sanatoriums

Cases

Minimal

Moderately

Advanced

Far

Advanced

Percentage of classifications of all
admissions to Ontario sana-
toriums (1943)

Percentage of classifications of all
active tuberculosis cases found
by mass surveys in Ontario (1943) .

Conclusions

From the facts presented the following conclusions
appear to be justified:

Table 6

Influence of Mass Radiography at Nopeming (Minnesota) Sanatorium

Moderately

Far

Minimal

Advanced

Cases

Num-

Per

Num-

Per

Num-

Per

ber

Cent

ber

Cent

ber

Cent

Active Tuberculosis

36.4

57.0

16.6

Questionably Active Tuberculosis

35.7

64.3

0.0

Inactive Tuberculosis

741

70.4

245

23.3

6.3

Total

770

66.8

304

26.4

6.8

Total Number of Cases, 1152

1. The eight-year stability of first admittances to
Minnesota sanatoriums of 15 per cent minimal cases and
85 per cent moderately advanced and far advanced cases
indicates that improvement is needed in either diagnosis
or case finding of tuberculosis, or both.

2. The marked decrease of first admittances of mini-
mal cases from rural districts over an eight-year period
emphasizes the need for greater diagnostic alertness in
rural Minnesota.

3. The disproportionately high number and percent-
age of cases first reported by death certificate call for
improvement in diagnostic acumen as well as extension
of case finding programs.

4. Experiences with mass radiography in Ontario and
in St. Louis County (Minnesota) indicate that it may
offer a solution to problems of diagnosis and case find-
ing in Minnesota.

5. Judging from experiences in St. Louis County and
in the Red Lake surveys, vacancies in Minnesota sana-
toriums may be replaced by waiting lists as soon as mass
radiography surveys are possible throughout the state.

References

1. Chesley, A. J : Personal communication.

2. Brink, G. C.: Tuberculosis Control. Canad. Pub. Health
J, 37: 1-6 (Jan.), 1946.

3. Hedberg, G. A.: Personal communication.

4. Callahan, F. F.: Personal communication.

TUBERCULOSIS CONTROL— A BARGAIN IN HEALTH

When compared with some other diseases, the purchase price of control of tuberculosis
may be considered a bargain. This is so because we know its cause. We know how it is
spread. We know how to prevent it, and we know how to treat it. Moreover, it costs pennies
to control it, and dollars to tolerate it.

To be sure, encouraging inroads against tuberculosis have been made. However, when
we critically appraise how little our present knowledge is actually put to work in the warfare
against it, we will be forced to conclude that we have but scratched the surface of potentials
in its prevention and control. — Robert E. Plunkett, M.D., New York State Department
of Health, January 1946.

April, 1946

109

The Hazard of Tuberculosis During Medical Training

An Abridged Report of a Case-Finding and Follow-Up Regime among
Women Medical Students , with an Effective Control
Program against T uberculosis *

Sarah I. Morris, M.D.

Chambersburg, Pennsylvania

The degree of hazard presented to the medical stu-
dent through exposure to tuberculosis "in line of
duty” has been a matter of controversy in medical edu-
cational circles, and reports from medical schools vary
greatly.

This diversity of opinion may be only a measure of
the degree of interest in the subject, the efforts to locate
diseased students, the criteria or methods used, or the
proportion of susceptible individuals in the various col-
lege groups.

Since it has repeatedly been demonstrated, by tuber-
culin testing in medical schools and schools of nursing,
that infection with tuberculosis and sensitization to tuber-
culoprotein are rapidly acquired while the student is in
training, it may be assumed that more rapid "seeding”
with tubercle bacilli takes place on exposure to tubercu-
lous patients and materials at the vulnerable age of the
young adult in medical school than in civilian life — a
risk intrinsic in the occupation, and against which the
individual cannot protect himself.

Most of the studies have been made in medical schools
where men students predominate, and comparisons have
been made chiefly with schools of nursing, whose stu-
dents do not parallel medical students in sex, age, or
duties. Since the morbidity and mortality rates in women
are earlier than in men, it is possible that in many men’s
schools the number of active clinical cases developing
during medical school years may not be significant under
normal conditions, but, with so high a degree of "seed-
ing” as has been demonstrated, more nearly complete
and accurate evidence might be expected were routine
entrance and periodic physical and X-ray examinations
made obligatory for internships and residencies. Cer-
tainly the number of medical student and physician pa-
tients in most sanatoriums suggests a greater eventual
morbidity rate than medical school reports indicate.

The new quicker and less expensive methods for mass
surveying developed during World War II will dem-
onstrate the incidence of disease in the young male
adult in the general population at comparable age levels.
These data should be helpful in comparative occupa-
tional studies.

The influence of sex is still controversial, but data to
date suggest an endocrine factor in tuberculosis. These
data include the earlier onset at adolescence in girls, the
earlier peak of mortality in women, the accelerated prog-
ress of the disease in the pregnant tuberculous woman,

*A more detailed report of this study will appear in the
American Review of Tuberculosis.

and the earlier drop in mortality at the climacteric in
women.

Objectives of the Survey

With these facts in mind a survey and follow-up pro-
gram for women medical students was proposed in 1931
by the professor of preventive medicine in the Woman’s
Medical College of Pennsylvania, the only medical school
in the United States exclusively for women.

It has been thought wise to report on the material
assembled and the results of the survey, in the hope
that its errors and achievements may be helpful to others
undertaking similar projects and that the results may
contribute data that will aid in clarifying certain doubt-
ful points regarding tuberculosis in medical schools.

The twelve years covered by the survey, 1932 to 1944,
paralleled a period of great unrest in the world. During
this period criteria for medical practice and teaching
methods, as well as methods for case finding and thera-
peutics for tuberculosis, were changing rapidly. In addi-
tion, the school surveyed was entirely reorganized and
there was consequently a considerable turnover in college
officials and faculty that alternately helped and hindered
the study.

The survey was to consist of observation of successive
classes of students for approximately a decade, by annual
routine Mantoux testing and X-ray inspections, with a
follow-up program for confirmation of diagnosis and
therapeutic guidance through the college course, and by
correspondence after the student left, in order to deter-
mine the ultimate results.

Upon conversion from Mantoux negativity to posi-
tivity, the student was to be warned of infection and
sensitization, reassured, and her co-operation solicited in
establishing as careful a regime of living as possible. She
was to avoid any additional known exposure, in order to
prevent overwhelming infection before stabilization, and
to report at intervals for further checking, and also at
any time she developed suspicious symptoms, or after
intercurrent illnesses.

Upon X-ray evidence of pulmonary involvement or
development of suggestive symptoms, the student was to
be warned of a probable early diseased process, reassured,
and her co-operation solicited for further study to learn
the extent of involvement. Repeated X-ray inspections,
recording the weight and temperature for a prescribed
period, the securing of a sedimentation rate and blood
examination, and a sputum examination by smear, cul-
ture, and guinea pig inoculation, if the facilities for it
were available, or of stomach contents otherwise, were
included in the study.

110

The Journal Lancet

The student with a minimal asymptomatic case was to
be allowed to remain in school till further evidence of
active tuberculosis was secured. Upon proof of activity
by X-ray or laboratory findings, the student was to be
advised to withdraw for treatment, regardless of symp-
toms. This procedure, by removing the student from the
infective environment of the medical college, gives her
the best chance for stabilization with no further disease.
All students suspected or watched for tuberculosis during
attendance at college were to be followed up after leav-
ing, to check subsequent developments.

The object of the survey was to learn the amount of
disease in the student body, the points of greatest hazard,
the type of disease encountered at the age and sex level
of the students, the progress of the disease under med-
ical school conditions, the adequacy of the control facili-
ties available, and the ultimate results. It was hoped that
an adequate control program might develop from the
survey.

The obstacles to carrying out this program were those
more or less common to all schools attempting such
studies. Indifference was encountered, owing to varying
opinions about the relative gravity of the minimal case
in the young adult medical student and differing degrees
of confidence in the changing criteria for diagnosis of
the primary "safe” case and in the adequacy of early
ambulatory treatment, as well as reliance on collapse
therapy to control conditions later.

Actual opposition was experienced from those who
placed academic objectives above the health of the stu-
dent or who relied on the ability of the student to "work
out her own salvation.” Sometimes the college manage-
ment, confronted by annoying adjustments to safeguard
the student, failed to co-operate. To some degree the
students themselves failed to realize the importance of
early treatment and were encouraged by the attitude of
college officials to procrastinate till serious disease de-
veloped.

Even after diagnosis and demonstration of progress
of the disease, decisions were colored by administrative
rules and regulations, by the advice of family physicians
who lacked full appreciation of the strain of modern
medical curriculums or by the advice of consultants
accustomed to more advanced disease, and by conflicting
medical and legal opinions in fellow faculty members
and corporation officials.

As a result of these obstacles the survey was begun
as a compromise undertaking. Case finding and follow-
up for confirmation of diagnosis were carried out in the
student health service under the direction of the pro-
fessor of preventive medicine, who was director of the
health service till 1941. At that time, under a new dean
and with a complete reorganization of the college and
hospital, the student health service was transferred to
the clinical medical department and became part of the
hospital service. The student clinic headquarters were
transferred to the out-patient department of the hospital,
and the clinic was thereafter manned by a series of
young clinicians under the supervision of the dean and
the superintendent of the hospital.

From the beginning clinical decisions as to disease
status, prognosis, treatment, and ultimate disposal of
cases were made through the professor of medicine, who
guided administrative action by clinical advice.

The procedure, however, was affected adversely by the
legal advice of the corporation lawyer, who decided that
proof of infectiousness of the student by demonstration
of tubercle bacilli in the sputum was necessary to require
withdrawal. This policy resulted in dangerous procras-
tination, progress of the disease, and its spread to others
while such proof by culture and guinea pig inoculation
was awaited. Similar results followed from allowing stu-
dents to return to college before complete or safe stabili-
zation; there was a 45 per cent relapse in such returning
students and a demonstrable spread of the disease to
others. It also caused a pyramiding of dangerous cases,
and from these cases several chains of student to student
contact cases were traced.

A second legal opinion, to the effect that the college,
which had no dormitories, could not dictate regarding
places of student residence, led to the housing of stu-
dents in a dwelling whose landlady was suspected of
having tuberculosis. Four consecutive cases developed
in the students living in this house, and from them three
other students were infected later when they became
roommates of these girls. Of this group two students
were permanently lost from the profession by with-
drawal and two, still unstabilized, will probably be lost;
to date these students have spent a total of twenty years
in recuperation.

Two years were required to secure routine Mantoux
testing, and four years passed before a complete routine
X-ray chest inspection of the students could be secured.

During this four-year interval 181 students were ob-
served. Eighteen cases of active tuberculosis developed
among them. Without the assistance of the X-ray, 50
per cent were diagnosed by signs and symptoms as hav-
ing fairly well advanced disease. Of these 18 cases three
only were arrested at a minimal stage, three died, and
two more were lost to the profession by permanent with-
drawal. A total of 47 % years of treatment were required
for those who recovered. This experience constituted a
challenge to further study and justified the need for
the survey.

Results of the Survey

The Mantoux testing of all students at entrance and
of all subsequent nonreactors yearly till 1937 and semi-
annually (fall and spring) thereafter revealed some sig-
nificant data.

During the twelve years of observation there was a
gradual reduction in the number reacting at entrance.
This finding suggests a parallel with the reduction in
mortality rates in the general public, which in turn sug-
gests fewer ambulatory "open cases” spreading disease.

Fdowever, in each successive year there was a rapid
increase in tuberculin reactions in each class, and by the
senior year each class reached 100 per cent positivity.
Similar surveys in men’s medical schools show a some-
what lower rate. Nevertheless, the rate is sufficiently
high among both men and women students to suggest

April, 1946

111

a corresponding exogenous infection during the four
years of attendance at medical school.

The most rapid increase occurred in the second half
of the second year, suggesting some unusual contact with
tubercle bacilli during that year. A search was therefore
made at the most likely points — in bacteriological and
pathological laboratory experiences, in handling infective
material, in autopsy work, and in the use of active cases
for physical diagnosis demonstrations.

No evidence of gross exposure was disclosed in the
laboratory experiences, but conditions in the autopsy
room of the city hospital were found to be potentially
hazardous. Attempts to rectify conditions there led
eventually to installation of foot-controlled wash basins
for students, to replace the use of the sink where speci-
mens were cleansed; establishment of a controlled regime
for collection, sterilization, and redistribution of soiled
gowns, gloves, and aprons, previously taken to students’
rooms; and a decrease in the time spent, per student,
in the autopsy room.

Significantly, during this study the first class to reach
the senior year without a case of active tuberculosis in
its membership was the first to have its autopsy experi-
ence under these bettered conditions.

No specific data were made available during this sur-
vey to determine the degree of hazard occasioned by the
use of active tuberculous cases for physical diagnosis dem-
onstration. However, since the only case showing phys-
ical signs is the advanced case, it may be assumed that
this experience is potentially dangerous for vulnerable
young adults. A more protective regime is advocated
than exists in most medical schools during the training
period.

It has been widely assumed that medical students de-
velop a rapid immunity, owing to continuing exposure to
tuberculosis, and the Mantoux positive reaction, per se,
is accepted by many as a criterion of safety in exposure
to the disease. Analysis of figures showing the relation
of Mantoux conversion to positivity to the subsequent
development of disease proves these assumptions to be
false. Of those developing active disease, 58 per cent
did so within six months after becoming tuberculin posi-
tive, 32 per cent within twelve months, 5 per cent within
twelve to eighteen months, and 5 per cent within two
years. This finding supports the claim that new sensi-
tization predisposes to disease.

In medical schools the tuberculin test is extremely im-
portant. Conversion to positivity constitutes a warning
against early subsequent exposure and against assigning
students to especially hazardous duties and to routine
section work in clinics and hospitals where active tubercu-
lous patients may be encountered.

Comparison of Mantoux reactions at entrance with
X-ray findings revealed that many showing X-ray evi-
dence of hilar calcified glands were negative to the tuber-
culin test. This phenomenon we had interpreted as sig-
nificant of loss of allergy following complete neutraliza-
tion of all the tuberculoprotein of an earlier infection,
with termination of the disease process. However, recent
work that appears to demonstrate the nonspecificity of
calcified hilar glands for tuberculosis throws doubt on

this interpretation and may necessitate a revision of our
whole concept of the prevalence of a harmless "infantile
type” of tuberculosis and our more or less arbitrary
division of the disease into childhood and adult disease
complexes.

The total number of students observed during this
period was 449. Among them 56 (12.5 per cent) active
cases of tuberculosis developed, 43 while the students
were still in college, and 13 relatively soon thereafter.
Minimal X-ray lesions were demonstrated in 19 others
who were never proved tuberculous by laboratory meth-
ods and who did not progress beyond the early minimal
stage — the so-called prephthisical case. These cases,
together with those showing at entrance evidence of
healed parenchymal lesions that remained quiescent and
those showing X-ray evidence of hilar calcified glands
only, are excluded from the totals analyzed.

The 56 cases were studied as to mode and time of
infection, transmission, disease development and prog-
ress, prognosis, and ultimate results.

The unusual development of fairly well advanced dis-
ease while the students were still in school, resulting
from delay in withdrawal after diagnosis had been estab-
lished, and the spread of disease to others from students
allowed to remain after evidence of progression, justifies
the original recommendation for early withdrawal from
the infective environment of a medical school.

Even after the student’s withdrawal, the results of de-
lay in seeking sanatorium treatment till further progress
prompted collapse therapy bear out the statement that
reliance on special means for collapse has encouraged a
dangerous laxness in securing adequate rest treatment for
the early minimal case and has robbed the young adult
of his best chance for early stabilization without further
disease progress.

The return of students before complete stabilization
resulted in a lamentable number of relapses. There was
a 45 per cent incidence of relapse in those returning after
treatment, and, in several instances, traceable spread of
disease to others.

Although X-ray evidence alone, at time of diagnosis,
is not a reliable index of the amount of disease or a satis-
factory basis for prognosis, nevertheless comparison of
such early evidence with later developments has been
helpful in evaluating types of cases and estimating the
probable outcome in a number of instances.

As elsewhere, the light flocculent shadows, usually in
the upper lung fields, in these young subjects, were found
most frequently to indicate early minimal tuberculous
lesions. Upon early withdrawal of the student, and
under a relatively short rest regime, these lesions were
usually promptly arrested, leaving little if any perma-
nent evidence of disease. In a few instances where com-
plete disappearance of a lesion was noted soon after
Mantoux conversion, allergic edema or patchy atelectasis,
so-called epituberculosis, may have accounted for the
X-ray shadows.

When these students did not withdraw, however, most
of their cases progressed as exudative processes. Five
typical minimal cases were aborted by early withdrawals,

112

The Journal Lancet

and seven students who attempted to remain went into
progressive disease.

The exudative-productive type gave a more hopeful
prognosis. Since healing has already begun, with care
the tendency to heal may continue, although the disease
may run a rather long course before stabilization. Fol-
lowing extreme fatigue, after experiencing superimposed
infections, or in gross exposure to further tuberculosis,
these students also may succumb and the exudative proc-
ess may outstrip the fibrotic.

In both these types of process, withdrawal and removal
from danger of added infection till fibrosis was com-
plete gave the best results. Four exudative-productive
cases, at first progressing satisfactorily, later developed
into active open cases with cavitation.

Twice a large caseous nodule of unusual density was
diagnosed as a calcified lesion and subsequently under-
went liquefaction and excavation, with positive sputum
and a febrile course. Such lesions need watching and
correlating with other signs and symptoms, such as fever
or sedimentation rate.

The greatest difficulty in early diagnosis consisted of
mistaken diagnosis of tuberculosis as nontuberculous
upper respiratory disease, when the associated increased
bronchovascular markings tended partially to obscure the
lung field — even in the presence of fever, loss of weight,
anorexia, and increased sedimentation rate. In one in-
stance, despite a familial history of tuberculosis and a
positive Mantoux reaction, the condition was diagnosed
as sinusitis, although the student showed fever, loss of
weight, and demonstrable rales. Sinusitis was the most
frequent interpretation of these early cases by the roent-
genologist.

Diabetes, endocarditis, and arthritis, with fever, mal-
aise, anorexia, elevated sedimentation rate, and pleuro-
dynia, also masked a concurrent tuberculosis by causing
a delay in the report of symptoms attributed to these
respective diseases.

Pleurodynia was reported sometime early in the course
of the disease by the majority of cases reviewed during
the survey, often before there was X-ray evidence of
disease. This warning symptom may serve, by prompting
more frequent X-rays, to diagnose disease at a very early
reversible stage.

Active disease usually developed during the last two
clinical years, even when infection occurred earlier, fre-
quently after upper respiratory infection or following
unusual strain, such as out-practice work or academic
examinations with irregular hours. The role of super-
imposed infection and fatigue in activating disease is
evident in these cases.

A notable exception to the development of disease in
the clinical years occurred in 1941, when the student
health service was transferred from the college to the
hospital. At this time student cases were cared for in
the hospital out-patient department, and the clinic for
students was located across a narrow corridor from the
city chest clinic, and the clinic patients used the same
waiting benches as the students.

An unusual number of severe tuberculin reactions were
experienced among the members of the first and second

year classes, and very soon thereafter, in the second half
cf the second year (the spring testing), an unusual num-
ber of active disease cases were disclosed, several of which
quickly developed into fulminating cases of a type rarely
seen today in the white race. Two of these students have
since died, and several still remain unstabilized.

In a class of 36, ten active cases developed, giving a
class morbidity rate of 27 per cent, a case fatality rate
of 20 per cent, and a mortality rate of 5.5 per cent.

No common source of exposure to active tuberculosis
could be located. It seems logical to conclude that an
unappreciated hazard existed for these young women at
an earlier stage than usual in their college experience,
when the student health service was transferred from the
department of preventive medicine, with its safer location
in the college building, to the hospital out-patient depart-
ment in close proximity to the city chest clinic.

A second exposure the same year for the second year
students — namely, in their autopsy experiences — presum-
ably overwhelmed their body defense mechanisms, allow-
ing for rapid disease development and the quick course
in the six fulminating cases in this group.

A similar episode has been reported in a middle west-
ern medical school where autopsy exposure and use of
active cases for demonstration were blamed for the un-
toward developments. Soon after this experience a set
of rigid rules regulating autopsy service and governing
technique for students, interns, residents, pathologists,
and visiting physicians, was adopted in the hospital in-
volved. Since the adoption of these regulations new
cases have been very rare, and these cases, diagnosed
early and given early treatment, have stabilized satis-
factorily.

Summary of Findings

In the total of 449 cases observed over twelve college
years, and followed after withdrawal for two to five
years, a total of 56 active cases of tuberculosis developed,
resulting in six deaths, two within a year of onset. Long
periods of semi-invalidism were experienced by an appre-
ciable number of others before stabilization of the dis-
ease; some are still incapacitated.

An infection and allergizing rate of 100 per cent while
in school, X-ray evidence of disease in 16.7 pier cent,
a morbidity rate of 12.5 pier cent, a case fatality rate of
10.7 pier cent, and a mortality rate of 1.3 per cent, de-
veloping in a medical school with every facility available,
present a situation that should challenge the interest of
medical educators and stimulate an investigation of the
extent of the problem in other medical schools and hos-
pitals.

Recommendations

The ultimate cost — in personnel lost from the profes-
sion, in time spent in recuperation (a total of more than
100 years in this small group) , in monetary expenditure,
and in disappointment and embitterment of students
forced to alter their life plans — makes this a serious
social problem, as well as a grave medical one.

The responsibility for solving this problem rests pri-
marily with the medical profession, and especially with
medical educators and hospital officials. The financial
burden eventually rests on the public, who must pay in

April, 1946

113

tax support for medical schools and hospitals, for the
care of the tuberculous in sanatoriums, and for public
health services to find and follow up cases. Unless this
responsibility is recognized and assumed by the profession
we may expect medical schools and hospitals to be held
responsible for the results under occupational disease
compensation laws.

When finally adopted in its entirety, the originally
proposed plan accomplished the aims and purposes of
its originators, though by a system of trial and error
and at much too high a price. The program should be
continued and expanded to include a case finding pro-
gram in all college and hospital personnel, including am-
bulatory and bed patients. Its application should also
be extended to the intern and resident training periods.

With some such program carried on in all medical
schools and hospitals the medical profession may even-
tually make its training period a safely regulated, even
though an essentially hazardous, experience for its young
acolytes. To do so, however, will require hearty co-
operation and eternal vigilance.

Conclusions

Tuberculosis is to date the major occupational disease
hazard of the student of medicine during the under-
graduate and early graduate years.

Infection with tuberculosis takes place readily in the
medical school, chiefly in the preclinical years, and dis-
ease may follow during the clinical or postgraduate train-
ing periods.

Tuberculosis occurs earlier and progresses more rap-
idly in women than in men. Accordingly, it will be
found more frequently in women during the medical
school years, and in men must be looked for especially
in the intern and resident years.

Autopsy service and the use of tuberculous patients in
physical diagnosis demonstrations and clinical training
constitute the chief sources of infection in routine med-
ical school procedures.

Where there is lack of appreciation of the gravity of
tuberculous disease in the young adult and reliance is
placed on doubtful or controversial criteria for diagnosis
and prognosis, or where there is undue confidence in the
later application of collapse therapy, delay occurs in
diagnosis and treatment, with increased danger to the
student.

When the withdrawal of diseased students is delayed
or students return before full stabilization, we may ex-
pect disease progression, relapse, and spread to others,
by student to student contact.

The ultimate cost of tuberculosis — to the student, in
time lost, expense of treatment, sacrificed career or even
life; to the medical school, in wasted educational effort;
to the profession, in loss of promising future physicians;
and, indirectly, to the public — is far greater than is gen-
erally realized.

Development and operation of an adequate control
program against tuberculosis in medical schools and hos-
pitals are imperative. The program should include case
finding and follow-up programs in medical schools;
establishment of safer techniques in autopsy rooms, lab-
oratories, clinics, and wards of hospitals; obligatory en-

trance and periodic examinations of interns and resi-
dents, including X-ray inspections; early removal of all
tuberculous individuals; and routine examinations of all
college and hospital personnel, including ambulatory and
bed patients.

The responsibility for safeguarding students and grad-
uates of medicine against tuberculosis rests with the med-
ical profession. Unless this responsibility is realized and
assumed compensation laws covering tuberculosis as an
occupational disease, already existent in some states, will
probably become general.

References

1. Banyai, K. L., and Caddes, A. V.: Diabetes and Tubercu-

losis. Arch. Int. Med., 74: 445 (Dec.), 1944.

2. Boucot, K. S.: Mass Radiography in Philadelphia. Phila-

delphia Med., 40: 1461 (July 7), 1945.

3. Cutler, J. W.: Harmful Influence of Pregnancy in Ad-

vanced Tuberculosis. Am. J. Obst. Gc Gynec., 47: 1, 1944.

4. Doran, Martha V.: Tuberculosis in Employed Women:

Morbidity and Mortality Trends in Relation to Age. Am. Rev.
Tuberc., 49: 170 (Dec.), 1944.

5. Feld, D.: The Significance of Tubercle Bacilli in Gastric

Contents. Am. Rev. Tuberc., 40: 481 (Dec.), 1944.

6. Fitz, R.: Concerning Interns and Their Health. J.A.M.A.,

117: 1125 (Sept. 26), 1941.

7. Heimbach, J.: Incidence of Tuberculosis in Young Adult

Women, with Special Reference to Employment. Brit. J. Tuberc.,
32: 154, 1938.

8. Hetherington, H. W., and Israel, H. C. : Tuberculosis in

Medical Students and Young Physicians. Am. J. Hyg., 31:2,
1940.

9. Hilleboe. H. E., and Morgan, R. H.: Mass Radiography

of the Chest. Chicago: Year Book Publishers, Inc., 1945.

10 Kennedy, J. A.: Pulmonary Complications of the Common
Cold and Sinusitis. Lancet, 1: 769 (Jan. 19), 1943.

11. Loffler, W., and Zwingl, F.: Primary Group Infection

with Tuberculosis in Military and Civil Life. Schweiz, med.
Wchnschr., 73: 761.

12. Long, E. R., and Lew, E. A.: Tuberculosis in the Armed
Forces. Am. J. P. H., 35: 469 (May), 1945.

13. Lurie, M. B.: Experimental Epidemiology of Tuberculosis:

The Prevention of Natural Air-Borne Contagion of Tuberculosis in
Rabbits by Ultraviolet Irradiation. J. Exper. Med., 77: 5 5 (June),
1944.

14. Mattison, B. F.: Some Factors Affecting the Early Diag-

nosis of Tuberculosis. Am. J. P. H., 34: 1 163, 1944.

15. Medlar, E. M., and Reid, A. C. : Demonstration of Tu-

bercle Bacilli in an Employee Group with Clinically Inactive Pul-
monary Tuberculosis. Am. Rev. Tuberc., 51: 490 (Dec.), 1944.

16. Morris, S. E.: Occupation and Tuberculosis. In Wampler

et al.. Principles and Practice of Industrial Medicine. Baltimore:
Williams 8C Wilkins Company, 1943.

17. Myers, J. A., Diehl, H. S., and Boynton, R. E.: Tubercu-
losis among Students and Graduates of Medicine. Ann. Int. Med.,
14:4 (March), 1941.

18. Myers, J. A., Harrington, F. E., and Suarez, G.: Detection

of Tuberculosis in Children. J.A.M.A., 128: 852 (July 12), 1945.

19. Nicholson, E. E.: Tuberculosis among Young Women.

New York: National Tuberculosis Association, 1938.

20. Palmer, C. E. : Non-Tuberculous Pulmonary Calcification

and Sensitivity to Histoplasmin. Washington: U. S. Public

Health Repts., 60: 19 (May 11), 1945.

21. Piersol, P. H.: Modern Methods Used in Finding Pulmo-

nary Tuberculosis and Treatment of the Asymptomatic Case. M.
Clin. North America, 29: 5, 1945.

22. Pollock, W. C., and Forsil, J. H.: Reinfection among Tu-

berculo-Allergic Doctors and Nurses at Fitzsimmons Hospital.
Am. Rev. Tuberc., 40: 444 (Oct.), 1939.

23. Rappaport, I.: Pre-phthysical Tuberculosis, J.A.M.A.,

27: 15 (Jan. 4) , 1945.

24. Reiser, D., and Downes, J.: Minimal Tuberculous Lesions

of the Lung. Am. Rev. Tuberc., 51: 393 (May), 1945.

25. Rich, A. R.: The Pathogenesis of Tuberculosis. Spring-

field: Charles C Thomas, 1944.

26. Saranac Symposium: Tuberculosis in Industry. New York:

National Tuberculosis Association, 1932.

27. Scatchard, G. N., and Duszynski, D. O.: Miniature Chest

X-Ray Films in a General Hospital. J.A.M.A., 127: 746 (March
31*), 1945.

28. Schultz, J. H.: Medical Students and Tuberculosis. J.

Lancet, 44: 96 (April), 1944.

29. Steinbach, M. M., and Duca, C. J.: Tuberculin Testing of
Medical Students, Am. Rev. Tuberc., 51: 478, 1945.

30. Terplan, Kornel: Anatomical Studies on Human Tubercu-

losis. Am. Rev. Tuberc., 51: 952, 1944/45.

31. Weinerman, E. R., and Coe, F. O.: The Control of Tu-

berculosis among Medical Students, with Additional Reference to
Interns and Student Nurses. J. Lancet, 42: 115 (April), 1942.

32. Westermark, N.: On Epituberculosis and Lung Atelectasis.

Acta radiol., 22: 501, 1941.

3 3. Wilson, J. L.: Recent Advances in the Treatment of Tu-

berculosis. M. Clin. North America, 29: 445, 1945.

114

The Journal Lancet

The Out-Patient Chest Clinic

John Francis Briggs, M.D., and Everett K. Geer, M.D.
St. Paul

The out-patient chest clinic at the Ancker Hospital,
St. Paul, holds a unique and enviable position. It
is unique in being situated in a general hospital, and
it is enviable in that the out-patient clinic, the general
hospital, and the tuberculosis unit are all under the same
roof. Because of this relationship all those interested in
chronic chest diseases are familiar with the problems of
the patient, whether he is confined to bed or ambulatory.

The chief functions of the out-patient department are
(1) the diagnosis of tuberculosis and (2) the post-sana-
torium care of the patient ill with tuberculosis. In addi-
tion the clinic cares for all patients who suffer from
nontuberculous chest diseases, for it is recognized that
patients with nontuberculous chest conditions often be-
come problems from the point of view of the diagnosis
of open tuberculosis. Lastly, the clinic provides rehabili-
tation programs for those who suffer from chronic pul-
monary diseases.

The patients who attend the chest clinic come from
many sources. They may be referred directly to the out-
patient department from other agencies, or they may be
referred from other departments in the out-patient service.
Many are referred directly from the general medical
department whenever the chest X-ray examination sug-
gests pulmonary disease. In order to avoid clerical over-
sight on these suspicious cases, the roentgenologist reports
directly to the chest clinic all questionable tuberculous
lesions seen on routine film taken of out-patients. Pa-
tients who are to have post-hospital or post-sanatorium
care are referred directly to the clinic at the time of their
discharge from the institution. The number of referrals
to the chest clinic can be greatly increased following in-
stallation of the 4 x 5-inch X-ray unit, because every
patient who enters either the hospital or the out-patient
medical department will have a routine chest X-ray
inspection.

When a patient is referred to the clinic for diagnostic
purposes he has already had a complete history and a
physical examination. In addition a hemoglobin, white
blood count, differential blood count, sedimentation rate,
blood Wassermann test, and urinalysis are done. A Man-
toux test is applied routinely to each patient in the chest
department. An X-ray film of the chest has already been
taken as a routine procedure. Further, in those patients
past the age of 45, or if otherwise indicated, a blood
sugar determination and a blood urea determination are
done. A routine electrocardiogram is also made on all
patients in the middle-aged group.

Other forms of laboratory work are requested when-
ever they are indicated. The sputum is examined rou-
tinely, and if repeated sputum examinations are negative
a gastric wash is made. The material thus obtained is
investigated by culture as well as guinea pig inoculation.
Any individual found to have active tuberculosis is re-
ferred to the hospital immediately. If the patient is

found to have arrested or apparently cured tuberculosis,
he remains under observation in the out-patient clinic.
Patients too ill to undergo the diagnostic survey in the
clinic are also referred to the general medical service for
such care.

At all times the out-patient department is in a posi-
tion to perform when indicated any special examination,
such as bronchoscopy, lipiodal injection, and allergy tests.
When a patient with open tuberculosis is admitted to
the hospital the clinic nurse immediately notifies the city
health department of the existence of the case. The
public health nurses then investigate all those who were
in contact with the case. These contacts are referred to
the city tuberculosis clinic, where a Mantoux test and
a routine chest film are made. If tuberculosis is found
the patient is referred to his family physician for further
advice.

The post-sanatorium care of tuberculous patients rep-
resents a large amount of time spent in the treatment
of tuberculosis. All such patients are referred to the
out-patient department at the time of their discharge
from the pavilion.

On their first visit to the clinic a hemoglobin, white
blood count, urinalysis, sedimentation rate, and an X-ray
examination of the chest are done. The patient is
weighed, his temperature is taken, and the blood pressure
and pulse rate are recorded. The patient is then ques-
tioned concerning his activities since leaving the pavilion,
and his chest is examined.

If the patient is doing well he returns in two months,
when he again undergoes the entire examination. If the
patient is raising sputum, it is examined for the tubercle
bacillus, and when indicated a gastric wash is repeated.

The patient’s return visits are graduated according to
his clinical progress. If he improves, his visits are spaced
until he is returning about every four months. At each
visit the entire examination and the laboratory work are
repeated. The patient is always examined and ques-
tioned concerning his progress. When the clinical course
is such that he is apparently cured, he is told to return
after a period of six months, at which time we again
repeat the laboratory work, the X-rays, and the physical
examination.

The return visits of the apparently cured patient are
so spaced that ultimately he returns annually, but it is
understood that he may return at any time that he feels
the need of care. A patient who fails to return at the
time indicated is notified by postal card, and, if he still
fails to return, the public health nurse is notified. She
visits the patient and attempts to teach him the need for
further and prompt observation.

During the time the patient is returning to the clinic
for observation and care, plans are made for his rehabili-
tation. If the patient’s occupation previous to his illness
is such that it does not jeopardize or interfere with his

April, 1946

115

recovery, he returns to work on a graduated time sched-
ule, and his hours of employment are gradually increased
until he works a full eight-hour day. When the patient
is economically secure he no longer returns to the clinic
but is referred to his private physician for care. Arrange-
ments are made for the Minnesota Department of Edu-
cation to rehabilitate those whose work before the onset
of tuberculosis was such as to jeopardize their recovery
were they to continue in it. Obviously, such rehabilita-
tion is a very important function of the out-patient
department.

Any patient suffering from a nontuberculous disease
of the chest, such as bronchial asthma, bronchiectasis,
and allergic conditions, such as seasonal pollenosis, with
or without asthma, is asked to return to the out-patient
department for observation and treatment. These pa-
tients are usually examined every three months. The
examination and re-examination are identical with those
used for patients suffering from tuberculosis. It is sur-
prising how frequently an individual who for many years
has apparently had asthma or bronchiectasis will sud-
denly be found to have open tuberculosis. For this rea-
son we feel that these people should be under constant
observation and should be followed in the same manner
as the individual who has or has had tuberculosis.

One of the outstanding features of the chest depart-
ment is the weekly conference concerning the patient.
This conference is held every Friday morning, and is
attended by all physicians responsible for the care of
the tuberculous patients. In addition, Dr. Richards
Aurelius, director of the X-ray department, is present,
and on most occasions Dr. John F. Noble, chief of the
laboratory at the Ancker Hospital, as well. At these
conferences the new patients who have been admitted
to the sanatorium are investigated, their records are re-
viewed, and treatment for each individual is suggested.
Any person who is a diagnostic problem is restudied.
The course of illness of patients ready for discharge
from the hospital is discussed, and recommendations for
discharge are made. These patients are then referred to
the out-patient department. Any type of collapse ther-
apy, such as surgical procedures, is discussed by Dr. D.
Greth Gardiner, chief of the thoracic surgery division.
Owing to these conferences we are all familiar with the
condition of the patient and with any problem concern-
ing his care, whether he is ambulatory or confined to
the hospital.

Necessary treatments for the patient in the out-patient
department are given by the physicians and nurses in
attendance in the clinic. The pneumothorax treatments
are given on different days from the regular chest clinic,
and are under the direction of Dr. George Roth. Pa-
tients receiving pneumothorax treatment are re-examined
and checked in the chest clinic at stated intervals, even
though they may be returning for air injections at weekly
or monthly intervals.

When it is considered that a patient has received pneu-
mothorax treatment over a sufficiently long period of

time, he is informed that it may now be well to abandon
the pneumothorax treatment. If the patient elects to
do so, the matter is discussed in the Friday conference.
If in the opinion of the group such a procedure is in-
dicated, the pneumothorax is gradually released. As
these patients return at stated intervals for examination
many problems other than tuberculosis arise, and all
these problems are handled through conferences with
the entire group on the tuberculosis division.

The tremendous advantage of being under the same
roof as the general hospital is seen daily when some
nontuberculous disease is found in the tuberculous pop-
ulation. In such cases we have at hand specialists who
are cooperative and willing to aid in any emergency that
may arise. This arrangement is of great help in handling
patients suffering from chronic lung afflictions.

In conclusion it may be emphasized that the chest
clinic in the out-patient department of the Ancker Hos-
pital is primarily interested in the diagnosis and post-
sanatorium care of any individual with tuberculosis, but
it is also interested in nontuberculous diseases of the
chest because of the frequent appearance of open tuber-
culosis in what was previously a nontuberculous disease,
and because tuberculosis frequently masquerades as some
other form of pulmonary disease.

The out-patient department is unique in its relation-
ship with the sanatorium division of the hospital for the
care of tuberculosis, and is also housed under the same
roof as the general hospital. This arrangement is advan-
tageous, for it aids in the care of both tuberculous and
nontuberculous patients.

The clinics are fortunate in the understanding of their
function by the members of the Welfare Board and
their secretary, Miss Ruth Bowman, and in having the
close cooperation and understanding of Dr. Thomas E.
Broadie, superintendent of the hospital. The hospital
and clinic are indebted to the Health Department, under
Dr. Robert B. J. Schoch, and to his nurses and staff,
for the follow-up examination of contacts and for bring-
ing patients back to the hospital and out-patient depart-
ment for further treatment and examination.

Dr. Edward Meyerding and his group in the Ramsey
County Public Health Service, as well as others interest-
ed in promoting the Christmas Seal Fund, have con-
tributed greatly to the function of the tuberculosis divi-
sion of the hospital by furnishing us with funds to pur-
chase a 4 x 5-inch X-ray unit.

Dr. Richards Aurelius, chief of the department of
roentgenology, and Dr. John F. Noble, chief of the
department of pathology, are valuable consultants to
the sanatorium division, and particularly to the out-
patient department, because of their wide knowledge of
tuberculosis in their respective fields and their willing-
ness to cooperate in the problems of the out-patient
department. Lastly, the entire division is indebted to
the general medical staff of the hospital and to the nurs-
ing staff for their kindness and consideration in helping
to care for patients afflicted with pulmonary disease.

116

The Journal Lancet

Who Should Have the Tuberculin Test?

Julius B. Novak, M.D.

Chicago

The value of the tuberculin test as a modern weapon
in the control of tuberculosis has been proved beyond
doubt. However, its effectiveness differs in various age
groups, localities, and races.

The answer to the question "Who should be tested
with tuberculin?” is relatively simple. Everyone should
be tested. However, we must not expect the same results
or the same epidemiological value from all groups. If
we expect a good clinical case yield from a case finding
project in children of preschool age, either by X-ray or
the tuberculin test method, we are certain to be disap-
pointed. The number of cases of reinfection type of
tuberculosis in this group is small, and in many places
this is true also of the primary type.

Then why do any tuberculin testing in this age group?
The answer is that, although the number of clinical cases
found is infinitesimal, these children possess a charac-
teristic that makes tuberculin testing imperative, namely,
that they have a limited contact with people and that
we can trace the source of the infection among them
much more easily than in any other age group.

As an example: A child, 314 years old, reacted to
tuberculin. As would be true in almost all children of
this age, the X-ray and physical examination were nega-
tive. Nevertheless, the test provided us with the impor-
tant fact that this child was infected with tubercle ba-
cilli. It was probable that the infection came from one
of her few adult associates. Tuberculin testing and X-ray
inspection of the immediate family revealed that an
uncle who was working every day as a railroad conductor
had open tuberculosis. Thus the tuberculin test led to
the discovery of a case of tuberculosis, the victim of
which was innocently but nevertheless dangerously infect-
ing a great many people. It also stopped the reinfection
of the child.

A great many pediatricians routinely tuberculin test
all infants. The infection attack rate is roughly one per
cent per year. The test has no value unless the source
of the infection is found. All adults with whom the
child who reacts has intimate contacts should be exam-
ined for contagious tuberculosis. We have been able to
find 40 per cent of the sources of infection in this
manner.

The grammar school group of children, aged 6 to 14,
has been extensively tested. The number of clinical cases
found has been small, and therefore some physicians
have advocated that tuberculin testing be discontinued
in this age group. In fact, only one case in five hundred
tuberculin reactors shows any lung pathology. The same
poor results are obtained with X-ray surveys when cases
of reinfection tuberculosis are sought.

However, when a tuberculin testing program is prop-
erly carried out a tremendous amount of good is accom-
plished. A program should not consist of a single test-

From the Tuberculosis Institute of Chicago and Cook County,

ing project, but should be repeated annually. All non-
reactors should be retested each year. Whenever some-
one becomes a reactor under these conditions we are
able to find the source much more easily, since we know
that the infection has occurred during the preceding
year.

Let me cite two examples. In a grammar school where
tuberculin testing was done for the first time the inci-
dence of reactors was about 10 per cent, the usual pro-
portion for this age group in the locality where they
were tested. We found two sisters, aged 8 and 12, who
were reactors. It was probable that they were not infect-
ed at school, because of the general low incidence of
reactors. In their home, however, it was found that the
father, though working every day, was an open case of
tuberculosis. The care and control of the case eliminated
further infection of the girls and also of the man’s
associates.

The second example occurred in a school where tuber-
culin testing had been done for a great many years. All
nonreactors were retested every year. One year during
the annual testing we found three of a family of six
reacting to tuberculin. All six had previously been non-
reactors. Close questioning disclosed that the three who
became reactors had spent a summer vacation at the
home of relatives, and a check of these relatives revealed
a previously unknown case of contagious tuberculosis.

The educational value of tuberculin testing is enormous.
Participation in such a project teaches more about tuber-
culosis than lectures or motion pictures can ever accom-
plish. A child with a tuberculin reaction will usually
remember to be examined at yearly intervals.

In the high school group the case finding potentiali-
ties increase. One in every two hundred tuberculin re-
actors will show some evidence of the reinfection type
of tuberculosis. During the last twelve years our per-
centage of high school reactors has dropped from 33
to 21 — an encouraging decrease in the incidence of
infection.

Owing to the greater number of adult contacts, it is
much more difficult to find the source of infection in
the high school group. However, as the following exam-
ple shows, an alert testing program can accomplish a
good deal in this direction. In one of our high schools
we observed that five girls from the same class who had
previously been nonreactors had become reactors. After
some investigation our nurse found that these girls were
working in a sausage factory after school hours. A sur-
vey of this small factory revealed a previously unknown
case of tuberculosis among the permanent workers.

A straight X-ray survey in the high school group is
very costly, since 80 to 90 per cent of the group are non-
reactors and do not need X-ray inspection of their chests.
The argument that everyone will be X-rayed, while only
60 per cent of the group is tested, and that we therefore

117

April, 1946

find more cases by X-ray, merely indicates that we are
trying to find an easy way out. A good testing program
will get out most of the school population.

The teachers and other personnel of the school should
be X-rayed, and any with suspicious lesions should be
tested with tuberculin and also with all other phases of
the examination necessary to determine whether the
lesions are tuberculous.

As the infection rate becomes less and less, college
students as a group have a lower percentage of reactors.
X-ray inspection of reactors shows evidence of lung dis-
ease in one in every 150. During the college years stu-
dents offer a great opportunity for teaching the story
of the spread of tuberculosis. The best way to learn

is by participation. The college student who reacts to
tuberculin knows what it means and is smart enough
to submit to periodic examination to detect the presence
of the reinfection type of tuberculosis.

When mass X-ray surveys reveal pulmonary densities
the tuberculin test should always be administered before
a diagnosis of tuberculosis is made. When there is no
reaction to an adequate dose of tuberculin, tuberculosis
is usually not the cause of the X-ray shadow.

In summary, I would say that everybody should be
tested with tuberculin. Such testing has different values
in different age groups, races, and localities. Neverthe-
less, tuberculin testing, properly used, is a very effective
weapon in the control of tuberculosis.

ANTECEDENTS OF THE NATIONAL TUBERCULOSIS
ASSOCIATION

. . . "There is a wealth of records to attest that the birth of the present National Tuber-
culosis Association was exceedingly painful. Differences of opinion there were, some mild,
others acrimonious. The principles of organization which we accept today with little thought
or question were fraught with bitterest debate at the beginning of the present century.

"It seems clear now that, broadly speaking, there were at least six forces or factors
which had to be welded into one to make the present national movement. Their impact on
society was not yet fully felt in 1892.

"The first force was exerted by a number of private physicians interested in tuberculosis
as a disease. Most of the leaders in this group were members of the American Medical Asso-
ciation and the American Climatological Association. These men were concerned primarily
with tuberculosis as a disease in the individual.

"The second influence was that of the public health officers in the respective states and
cities throughout the country. Practically all of these men were members of the American
Medical Association and the American Public Health Association. They were interested in
tuberculosis largely as a problem affecting the public health. In this connection it should be
remembered that in 1900, the death rate from tuberculosis in the United States was 194 per
100,000 of population. The disease accounted for 1 death in 9 and was far and away the
leading cause of mortality. The public health officials were, therefore, acutely conscious of
the need for some action which would give promise of a reduction in such menacing figures.

"The third influence was that of the physicians who had established institutions for the care
and treatment of tuberculosis or were engaged in medical service in such institutions. These
men were comparatively few in number but wielded a large influence in the discussions of
tuberculosis in the organized medical, climatological and public health associations.

"The fourth influence was that exerted by laymen who recognized the devastation wrought
by tuberculosis among the people and who gave thought or financial assistance to bring about
an organized resistance against the disease. At the outset, this group was small. It was re-
cruited among the philanthropists, lawyers and those whom we term today, social workers.
They were interested in any proposal which gave promise of alleviating the vicious social effects
of the disease.

"The fifth force came from a minute group which devoted itself to the organization of
the campaign against the disease. Today they are termed 'tuberculosis secretaries.’ They were
interested in the disease as a medical, institutional, public health and social problem. They
later became one of the chief forces in the welding process.

"A sixth factor was the attitude of the victims of the disease, their families and friends.
That this group was virtually mute but ready for a unified leadership is attested by the sub-
sequent history of the movement in this country.

"Obviously, it must be borne in mind in any such categorical classification of forces that
there were individuals in each of the groups who had a wider view of the problem. It is only
necessary here to point to such men as Drs. Vincent Y. Bowditch, Edward L. Trudeau,
William Osier, Hermann M. Biggs, Lawrence F. Flick, Henry Barton Jacobs and Edward
O. Otis, to mention a few of the outstanding leaders. They were not alone interested in the
medical aspects of tuberculosis but were equally concerned with the possibilities of prevention.”
— Robert G. Paterson, Secretary, Committee on Archives, National Tuberculosis Association.

118

The Journal Lancet

Report of a One- Year Survey of a Diagnostic
Tuberculosis Service in a General Hospital

Willard E. Peterson, M.D.

Minneapolis

For several years the Minneapolis General Hospital
has maintained an active tuberculosis control program
within the institution. The procedure has been to apply
a Mantoux test routinely to all new hospital admissions
and to take chest X-ray films of all reactors. By this
method we endeavor to screen out all unsuspected open
cases on the hospital wards who might constitute a dan-
gerous source of exposure to other patients and to the
hospital personnel.

Until recent months it was found to be most practical
to engage one person, a part-time nurse, to do all the
tuberculin testing and recording. However, the shortage
of nurses has made it necessary for the hospital clerks
and interns to assume this function. We hope the first
method can soon be reinstated. All suspected cases found
are isolated on the tuberculosis unit. This unit has an
eight-bed capacity, all single rooms, and is located in the
contagion unit.

The hospital staff has attempted to detect and isolate
all cases of suspected tuberculosis as quickly as possible
and to make an accurate specific diagnosis of the disease
process before final disposition of the case. Toward this
end several diagnostic procedures are employed, i.e., the
tuberculin test, X-ray inspection, sputum and gastric con-
tent smears, and guinea pig inoculation. Since difficulty
arose from false positive findings with the smear tech-
nique alone, we have recently used culture methods to
complement guinea pig inoculation. The results have
been gratifying. Sternal aspiration has proved a very
useful adjunct in the diagnosis of miliary tuberculosis
during life."1'*

Table 1

jail and workhouse, those referred by the Minneapolis
Public Health Service as diagnostic problems or as con-
stituting a health menace to the community, those re-
ferred by private doctors and private hospitals for isola-
tion and diagnosis, and, finally, those patients seeking
hospital care on whom the admitting diagnosis was sus-
pected tuberculosis. The remaining patients (31.5 per
cent) were those admitted to the hospital on other serv-
ices but in whom tuberculosis was later suspected, with
resultant transfer to the contagion unit.

Table 2

Showing Distribution of Patients According to Diagnosis

Diagnosis

Number of
patients

Percentage
of Total

Active tuberculosis

53.2

Inactive tuberculosis

18.9

No tuberculosis

27.9

Total

143

100.0

Of the 143 cases admitted, active* tuberculosis was
diagnosed in 76, or 53.2 per cent (Table 2). The value
of an active tuberculosis control program and a hospital
staff alert to its enforcement is evident when it is noted
from Table 1 that 32 of the 76 active cases of tubercu-
losis, or 42 per cent, were first admitted on other hos-
pital services and were therefore, until the time of trans-
fer, an unsuspected source of infection to other patients
and the hospital personnel.

Table 3

Showing Age Distribution of Cases of Active Tuberculosis

Showing Source of Patients Admitted on the Tuberculosis

Service,

in Relation to Diagnosis

Number

admitted

transferred

direct to

from other

Diagnosis

service

services

Active tuberculosis

Inactive tuberculosis

No tuberculosis

Total

Percentage

68.5

31.5

Age Group

Number of
Cases

Percentage
of Cases

0-19 ..

2.6

20-29

11.8

30-39

13.2

40-49 ....

18.5 46.1

50-59

10.5

60-69

23.7

70-79

17.1

80 up

2.6 54.9

Total

100.0

During the year 1945 a total of 143 patients, repre-
senting 1.7 per cent of 8740 hospital admissions, were
admitted to the tuberculosis service. Most of these pa-
tients (68.5 per cent) were admitted directly from the
receiving ward (see Table 1). They include patients
suspected of tuberculosis who were referred from the
hospital out-patient clinic, those sent in from the city

From the Tuberculosis and Internal Medicine Services, Min-
neapolis General Hospital.

That active tuberculosis is becoming relatively more
common in the older age groups is illustrated in Table 3.
Here it is shown that 73.4 per cent of the active cases
were over 40 years of age, 54.9 per cent were over 50
years of age, and 44.4 per cent, or almost half the cases,
were over 60 years of age. While it is true that the age
incidence would probably closely parallel the average age
of patients admitted to a charity hospital during a war
year and a prosperous year, nevertheless, tuberculosis in
the population of this community is apparently becom-

April, 1946

119

ing more and more a problem of the older age group.
This fact would be expected from the known exposure
of the_older generation to tuberculosis compared with the
decreased exposure and decreased incidence of primary
infection in the younger age group.* 1 2 3

Table 4

Showing Type of Lesion and Stage of Activity
of Active Tuberculosis

Below Above Total Percentage
age 50 age 50 Number of Group I

Group I

Pulmonary lesions

Far advanced 16 21 37 56.1

Moderately far advanced 9 12 21 31.8

Minimal 4 4 8 12.1

Total, Group I 66

Group II

Extrapulmonary lesions 12 8 20

Grand Total 86

Percentage, Group I 76.7

Percentage, Group II 23.3

Pulmonary lesions as seen in Table 4 represent 76.7
per cent of all active tuberculous lesions. Some patients,
of course, had both pulmonary and extrapulmonary
lesions, accounting for the fact that the number of
lesions is greater than the number of cases. Regrettably,
almost 88 per cent of the patients with pulmonary lesions
were advanced cases at the time the diagnosis of activity
was made. There was no appreciable difference in this
respect between the patients grouped above or below the
age of 50.

Table 5

Types and Number of Extrapulmonary Tuberculosis Lesions

Type

Miliary

Renal

Larynx

Pleurisy with effusion

Enteritis

Bone

Otitis

Adenitis

Number
of Cases
6
2
2
5
2
1
1
1

The type and distribution of extrapulmonary lesions
are shown in Table 5. There were six cases of miliary
tuberculosis, most of whom were diagnosed during life
by sternal aspiration. Five of these patients had gener-
alized miliary tuberculosis and have since expired. The
other patient, who had miliary tuberculosis of the bone
marrow associated with tuberculous adenitis, is living
and in good condition over one year after initial diag-
nosis.

Table 6

Other Pathological Conditions Suspected as Tuberculosis

Diagnosis

Bronchiectasis

Pneumonia, upper lobes .
Pneumonia, unresolved .
Cardiac decompensation
Pulmonary infarction
Bronchogenic carcinoma
Acute lung abscess

Metastatic carcinoma

Nontuberculous empyema

Luetic endometritis

Others

Number
of Cases
7
5

4
2
1
1
1
1
1

Numerous other conditions are frequently mistaken
for tuberculosis, and the differential diagnosis is often
difficult and time consuming. These conditions are listed
in Table 6. This table does not include patients who
proved to have inactive tuberculosis but were admitted
suspected of activity because of acute upper respiratory
infections, bronchopneumonia, or other conditions.

As would be expected, chronic bronchiectasis, owing
to the productive cough and episodes of hemoptysis asso-
ciated with it, is the condition most commonly suspected
clinically as tuberculosis. The X-ray shadows of upper
lobe pneumonias, of both acute and unresolved types,
caused some difficulty in differentiation. That cardiac
decompensation (left ventricular type) was so commonly
confused with tuberculosis is a little surprising. How-
ever, in pulmonary infarction, particularly where either
upper lobe is involved and hemoptysis is present, differ-
entiation must be made by careful study. Other condi-
tions found included bronchogenic and metastatic car-
cinomas and acute lung abscess. One patient admitted
with a histologic diagnosis of tuberculosis endometritis
was later found to have a luetic involvement of the
endometrium.

Table 7

Mortality

Total number of admissions 143

Number of deaths 21

Mortality rate (per cent) 14.6

Autopsy percentage 42.8

The mortality figures for the service are given in
Table 7. The mortality rate of 14.6 per cent seems
rather high, but it must be realized that most of these
patients were admitted in a moribund state; in other
cases terminal bronchopneumonia or pulmonary edema
could not be differentiated from tuberculosis and necessi-
tated admission on that service. Four of the deaths in
this hospital were due to generalized miliary tuberculosis.
In eight other patients tuberculosis was considered a con-
tributing cause of death, making a grand total of twelve,
or 57.2 per cent of the cases.

References

1. Myers, J. A.: Tuberculosis among Persons over Fifty

Years of Age. Geriatrics, 1: 27-39, 1946.

2. Schleicher, E. M.: Miliary Tuberculosis of the Bone Mar-
row. Am. Rev. Tuberc., 53: 115, 1946.

3. Schleicher, E. M.: Pernicious Anemia and Miliary Tuber-
culosis of the Bone Marrow Organ. Am. J. . Clin. Path.,
15: 402, 1945.

120

The Journal Lancet

. . . fllEET OUR (MRIBUTORS . . .

Dr. Jay Arthur Myers, editor of this special tuber-
culosis issue, is also chairman of the Board of Editors of
the Journal Lancet, as well as chairman of the Edi-
torial Board of Diseases of the Chest, official journal of
the American College of Chest Physicians, and an Asso-
ciate Editor of Geriatrics. Dr. Myers is Professor of
Internal Medicine and Preventive Medicine at the Uni-
versity of Minnesota, and Chief of Tuberculosis Service,
Minneapolis General Hospital. He is a member of many
professional societies, including the American College of
Chest Physicians, the American Association of Thoracic
Surgeons, the American Trudeau Society, and the
American College of Physicians.

Dr. Kendall Emerson, of New York, distinguished
surgeon who contributes the introduction to this special
issue, has been managing director of the National Tu-
berculosis Association since 1928. A graduate of Am-
herst College and Harvard Medical School, Dr. Emer-
son has been consulting surgeon of Worcester Memorial
Hospital, where he began the practice of orthopedic and
general surgery, since 1928. He is a Fellow of the Amer-
ican College of Surgeons and a member of many pro-
fessional societies.

Dr. Oscar A. Sander of Milwaukee is a graduate
of the University of Wisconsin and had his medical
training at the University of Pennsylvania (M.D., 1927),
with graduate work in internal medicine at the Univer-
sity of Pittsburgh Medical School in 1928—29 and in
pathology at the University of Vienna in 1930. His
specialties are internal medicine and diseases of the chest.
He is a Fellow of the American College of Physicians
and a member of the American Trudeau Society, the
American Public Health Association, and the American
Association of Industrial Physicians and Surgeons.

Dr. Herbert L. Mantz of Kansas City, Missouri,
has practised in that city for 24 years. He is a graduate
of the University of Missouri and had his medical train-
ing at Jefferson Medical College (M.D., 1920). He in-
terned at the Kansas City General Hospital and the
Kansas City Tuberculosis Hospital. His specialty is dis-
eases of the chest. Dr. Mantz is Medical Consultant in
Vocational Rehabilitation in Missouri, Consultant to the
U. S. Public Health Service, and Regional Consultant
of the U. S. Veterans Bureau. A member of the Jack-
son County Medical Society, the Missouri State Medical
Association, the American Medical Association, the Kan-
sas City Southwest Clinical Society, the American Col-
lege of Chest Physicians, and the American Trudeau
Society, Dr. Mantz is also President of the Missouri
Tuberculosis Association and Governor for Missouri of
the American College of Chest Physicians.

Dr. Loren L. Collins of Ottawa, Illinois, is past
president of the Mississippi Valley Trudeau Society, as
his article indicates. He is a graduate of the University
of Illinois College of Medicine (1925), and has his office
at the La Salle County Tuberculosis Sanatorium.

Dr. Edwin J. Simons, Chief of the Medical Services
Unit of the St. Paul Division of Social Welfare, and
President of the Minnesota State Medical Association,
has practiced medicine in his home state for 22 years.
He is a triple graduate of the University of Minnesota
(B.S., B.M., and M.D., 1924). His specialties are in-
ternal medicine and diseases of the chest. Dr. Simons
is a member of the Upper Mississippi Medical Society,
the American Medical Association, the American College
of Physicians, the American College of Chest Physicians,
and the American Academy of Tuberculosis Physicians.

Dr. Sarah I. Morris, Professor of Preventive Medi-
cine at Wilson College, is a graduate of the Woman’s
Medical College of Pennsylvania. Her specialty is tuber-
culosis.

Dr. John Francis Briggs of St. Paul is a graduate
of the University of Minnesota Medical School (1929)
and a Diplomate of the American Board of Internal
Medicine. He is physician to the Ancker Hospital and
also Clinical Assistant in Medicine, University of Min-
nesota Medical School. He is a fellow of the American
College of Physicians, a Fellow of the College of Chest
Physicians, and a member of the American Medical
Association, the American Trudeau Society, the Minne-
sota Society of Internal Medicine, and the American
Heart Association. His specialty is internal medicine.

Dr. Everett K. Geer, chief of the tuberculosis de-
partment at Ancker Hospital, St. Paul, is also Clinical
Assistant Professor of Internal Medicine at the Univer-
sity of Minnesota. He is also a graduate of the Univer-
sity of Minnesota (B.S., M.D., 1917), with graduate
work at the Trudeau School. Dr. Geer has practised in
St. Paul for 27 years. A Diplomate of the American
Board of Internal Medicine, his specialty is diseases of
the chest. He is a member of the American Medical
Association, the American College of Physicians, the
Central Society for Clinical Research, the American Tru-
deau Society, and the Minnesota Society of Internal
Medicine.

Dr. Julius B. Novak, Medical Director of the Tu-
berculosis Institute of Chicago and Cook County, is a
graduate of the University of Illinois (B.S., M.D.,
1926), and was resident physician of Cook County Hos-
pital in 1927-28. Dr. Novak is a Fellow of the Ameri-
can College of Chest Diseases and a member of the
Trudeau Society, the Chicago Tuberculosis Society, and
the American Medical Association, as well as a member
of the Tuberculosis Committee of the American School
Health Association. He has practised in Chicago for
19 years.

Dr. Willard E. Peterson is a graduate of the Uni-
versity of Minnesota Medical School (M.B., 1942,
M.D., 1943), and has been with the Minneapolis Gen-
eral Hospital since 1943. He is a member of the Min-
nesota Trudeau Society.

JOtfcNAL

lanIcet

Serves the

MINNESOTA, NORTH DAKOTA,

Medical Profession of

SOUTH DAKOTA and MONTANA

North Dakota State Medical Assn. South

Dr. James F. Hanna, Pres. Dr.

Dr. A. E. Spear, Pres. -Elect Dr.

Dr. L. W. Larson, Secy. Dr.

Dr. W. W. Wood, Treas. Dr.

North Dakota Society of South

Obstetrics and Gynecology Dr.

Dr. E. H. Boerth, Pres. Dr.

Dr. Paul Freise, Vice Pres. Dr.

Dr. G. Wilson Hunter, Secy.-T reas.

Sioux

Minneapolis Academy of Medicine Dr.

Dr. Karl W. Anderson, President Dr.

Dr. Russell W. Morse, Tice Pres. Dr.

Dr. J. C. Miller, Secretary Dr.

Dr. Ragnvald S. Ylvisaker, T reasurer
Dr. Henry E. Hoffert, Recorder

Dr J . O. Arnson
Dr. A. B. Baker
Dr. D. S. Baughman
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W. A. Fansler

Dr. A. R. Foss
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. J . Mabee

ADVISORY COUNCIL

Dakota State Medical Assn.
William Duncan, Pres.

F. S. Howe, Pres.-Elect
H. R. Brown, Vice Pres.
Roland G. Mayer, Secy.-T reas.

Dakota Public Health Assn.

J. M. Butler, Pres.

C. E. Sherwood, Vice Pres.
Gilbert Cottam, Secy.-T reas.

Valley Medical Assn.

D. S. Baughman, Pres.

Will Donahoe, Vice Pres.

R. H. McBride, Secy.

Frank Winkler, Treas.

Montana State Medical Assn.

Dr. S. A. Cooney, Pres.

Dr. M. A. Shillington, Pres.-Elect
Dr. R. F. Peterson, Secy.-T reas.

Northwestern Pediatric Society
Dr. G. B. Logan, Pres.

Dr. Geo. Kimmel, Vice Pres.

Dr. Northrop Beach, Secy. -Treas.

Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.

Dr. R. C. Webb, Secy .-Treas.

American Student Health Assn.

Dr. Ralph I. Canuteson, Pres.

Dr. Glenadine Snow, Vice Pres.

Dr. G. T. Blydenburgh, Secy. -Treas.

BOARD OF EDITORS

Dr. J. A. Myers, Chairman

Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C H. Nelson
Dr. N. J . Nessa
Dr. Martin Nordland
Dr. I . C. Ohlmacher
Dr. K. A. Phelps
Dr. C. E. Sherwood

Dr. M. A. Shillington
Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. S. E. Sweitzer

Dr. W. H. Thompson
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H M N Wynne
Dr. Thomas Ziskin,
Secretary

LANCET PUBLISHING CO., Publishers , 84 South Tenth Street, Minneapolis 2, Minnesota

Minneapolis, Minnesota, April, 1946

TUBERCULOSIS IS CONTAGIOUS

Several centuries before Christ the contagion of tuber-
culosis was suspected. Despite the fact that Villemin
proved its contagiousness beyond doubt in 1866, and
Koch actually demonstrated the specific organism, we
find constitution, inheritance, race, and a dozen other
factors being emphasized as the cause of tuberculosis,
sometimes almost to the exclusion of the tubercle bacillus.
One disease after another, like diphtheria and typhoid,
were accepted as contagious and so treated, but when
tuberculosis was proved to be contagious many persons,
and even some physicians, refused to accept the evidence.

Probably this attitude was due to the fact that the
primary lesions of tuberculosis usually are not visible on
the surface of the body. They do not cause significant
illness, and therefore in the great majority of cases they
are not known to exist. Thus, individuals who are ex-
posed to contagious cases of tuberculosis go blithely on

assuming that the disease is not contagious, despite the
fact that they themselves have developed primary lesions
as a result of the exposure. Usually it is months, years,
or decades later that clinical manifestations appear — so
long after the contact that they are not associated with
the exposure, and therefore the disease often is not rec-
ognized as contagious.

Not until we had an accurate and specific test for
primary tuberculosis could the more detailed facts con-
cerning its contagion be determined. It was then discov-
ered to be one of the most contagious of all diseases.
For example, a tuberculous teacher could transmit bacilli,
resulting in primary tuberculosis as manifested by the
tuberculin reaction, to nearly all her pupils, and tubercu-
lous parents could transmit the disease to all their
children.

Long after we instituted strict contagious disease tech-
nique in the management of persons suffering from such

121

122

The Journal Lancet

diseases as scarlet fever, we continued to manage cases
of tuberculosis with almost no regard for its contagion,
and in many places we still do. About all we did to
protect fellow patients, personnel, and visitors was to ask
the patient to cover the mouth with gauze or paper nap-
kin when coughing or sneezing and to collect sputum in
a special container. These procedures are inadequate,
as demonstrated beyond doubt by the large number of
students of nursing and medicine who develop pri-
mary tuberculosis through contact with patients in sana-
toriums and hospitals, with consequent illness and death
for many in later years. Any hospital today that would
ignore the contagion of such diseases as scarlet fever,
diphtheria, and typhoid fever, as is done in the case of
tuberculosis, probably would be voted out of state and
national hospital organizations and would have many
persons claiming compensation for disease contracted
from patients.

It it one of the outstanding paradoxes in medicine
that we build institutions for the tuberculous for the
express purpose of protecting girls and boys against
contagion in their homes and communities, and then
ask, or even demand, that the same girls and boys come
to these institutions to work with patients, without ef-
fective protection against the disease, despite the fact
that in such institutions there is more intimate contact
with and exposure to patients than there would have
been in their own homes. Battles are waged against con-
tagion as long as patients are in their own homes and
communities, but as soon as they are admitted to hos-
pitals and sanatoriums peace and tranquillity reign, as
though the mere admission to an institution rendered
the disease noncontagious or domesticated tubercle bacilli.

The hazard of contact with contagious cases of tuber-
culosis in homes, places of work, hospitals, and sana-
toriums has been clearly demonstrated. Nevertheless,
some schools and nursing organizations have maintained
that a nurse is not well qualified to practise her profes-
sion unless she has had tuberculosis training that brought
her in contact with patients. Although there is consid-
erable diversity of opinion as to whether work with tuber-
culous patients is necessary, certainly no one could object
to such a service if contagion were given the same con-
sideration as it is in other transmissible diseases.

At the present moment the LJnited States Veterans
Administration is facing a serious and difficult problem
with reference to the contagion of tuberculosis. Already
there are many thousand veterans of World War II,
and there are still a considerable number of veterans of
World War I, who have clinical tuberculosis. The re-
sponsibility of the Veterans Administration is: (1) to
those who visit tuberculous patients in the hospitals;
(2) to the veterans themselves who are tuberculous but
may be cross-infected; (3) to every member of the per-
sonnel working on tuberculosis services or coming in con-
tact with tuberculous veterans in any way; and (4) to
the general public, by reducing leaves of absence of con-
tagious cases to an absolute minimum and making some
provision for those who leave institutions against medical
advice, as well as for those who refuse to enter institu-
tions. Exceedingly close co-operation between the Vet-

erans Administration and the health officers of the coun-
try is imperative. At this moment it is only the official
health officer who has the authority to enforce isolation
of contagious cases of tuberculosis. Unless the health
officer is alert and uses his power promptly there is con-
siderable danger that there will be an appreciable increase
in tuberculosis among the citizens of this country.

The procedures recommended for tuberculous veterans
are equally applicable to tuberculous civilians. In both
groups there are two important considerations: first, the
protection of the public against contagion; and, second,
adequate treatment of the tuberculous patient. On the
whole such treatment is far more successful when the
activities of the patient are rigidly restricted and all in-
dicated treatment is administered until the disease is
noncontagious and the individual’s working capacity is
restored.

Although no immunizing agent, such as BCG, has
been proved sufficiently efficacious for general adoption,
there is much that can be done to protect the personnel
of hospitals and sanatoriums and all others concerned
against the contagion of tuberculosis. Strict contagious
disease technique, rigidly enforced, is capable of reduc-
ing the infection attack rate among personnel on tuber-
culosis services to almost that of the general population,
as has been demonstrated at the Minneapolis General
Hospital.

Unless a hospital or sanatorium is willing to afford
every known protection to its personnel on tuberculosis
services and to study methods of improving and offering
greater protection, professional students should not be
permitted on these services. Each member of the per-
sonnel of every classification should be informed of the
contagiousness of the disease and their salaries should
be definitely higher than those of personnel employed on
noncontagious services. Indeed, their pay should be com-
mensurate with the risk involved.

J.A.M.

TUBERCULOSIS PREVALENCE REVEALED
THROUGH AUTOPSIES

Pathologists, diagnosticians, and research workers in
every field of scientific medicine agree that autopsy find-
ings are among the most important data available to the
practicing physician. It was the universal performance
of necropsies in the hospitals of Vienna that built that
city up to its reputation as the outstanding medical
center for postgraduate study fifty years ago. When a
case that had puzzled diagnosticians was zu Grunde ge-
gangen the news quickly spread, and those interested
might attend the post mortem, for, by an orderly ar-
rangement of schedules, information concerning the time
and tables assigned to bodies from the various Ab-
teilungen were posted in the Abduzier Z.itntner of the
pathological building.

It was never considered sufficient simply to determine
the immediate cause of death; every pathological finding,
large or small, had to be recorded. That was how
Weichselbaum learned to postulate that "fast Jedermann
hat T uberkulose.” As Hofrat Weichselbaum, still huge
and erect in his eighties, devoted his time chiefly to a

April, 1946

123

laboratory across the corridor, Anton Ghon, after whom
the Ghon tubercle was named, presided over the teach-
ing of gross pathology based on the day’s post-mortem
findings at 5 p.m. Not only was he a wonderful teacher
on such occasions; he will be remembered also for the
courteous 'Meine Achtung, Herr Kollege,” with which
he invariably greeted visiting physicians at any time of
the day when they were inclined to drop in and see him
at work.

Hospitals in this country receive a higher rating by
inspection and accrediting committees if they show a
large percentage of autopsies performed in their institu-
tions. In obtaining consent for an autopsy it is poor
practice to state that it is in the interest of science
or that the cause of death was unknown; if the cause
was actually unknown, then it is a coroner’s case. Better
far to suggest the possibility of finding something not
directly a factor, the knowledge of which should be
revealed for the benefit of the family and immediate
associates for their future guidance. And, finally, we
should like to make a plea for more refinement and
dignity in post-mortem procedures. They need not be
more gruesome than surgical operations in our hospitals.

A. E. H.

ANNOUNCEMENTS

Clinical Congress, American College
of Surgeons

The American College of Surgeons announces that
arrangements have been completed for its 3 2d Clinical
Congress, to be held at the Waldorf-Astoria, New York,
September 9-13, inclusive. This will be the first clinical
congress since the meeting in Boston in 1941. Since that
time 2744 surgeons have been received into fellowship
in absentia. The formal initiation ceremonies are ex-
pected to be especially impressive this year because of
the large number of new fellows admitted during the
past four years.

Officers, regents, and governors have remained in of-
fice since 1941 because of the cancellation of annual
meetings, and special interest will therefore attach to
the installation of the officers-elect, headed by Dr. Irvin
Abell as president. The presidential address will be
given by Dr. W. Edward Gallie of Toronto.

Dr. Howard A. Patterson is chairman and Dr. Frank
Glenn is secretary of the committee on local arrange-
ments.

Annual Meeting, American College of
Chest Physicians

The 12th annual meeting of the American College of
Chest Physicians will be held at the Sir Francis Drake
Hotel, San Francisco, June 29-30 and July 1-2.

The next oral and written examinations for fellowship
in the College will be held at San Francisco on June 29.
Applicants who plan to take the examinations should
communicate with the Executive Secretary at 500 North
Dearborn St., Chicago 10, Illinois.

Nine Clinics for Crippled Children
Announced in Minnesota

Nine district clinics have been scheduled for this spring
by the Crippled Children Services of the Minnesota Divi-
sion of Social Welfare. These clinics, part of the services
financed by the federal and state government, provide
medical examination and recommendation for treatment
for crippled children and young people under 21 years
of age and vocational advice for those over 14. The
clinic staff includes two orthopedic surgeons, a pediatri-
cian, a vocational rehabilitation worker, a public health
nurse, physical therapists, medical social workers, and
public health nurses.

The schedule of the clinics follows. St. Cloud, April
6, serving Stearns, Benton, and Sherburne counties.
Austin , April 13, serving Mower, Freeborn, Steele, and
Dodge counties. Thief River Falls, April 27, serving
Pennington, Marshall, Red Lake, Roseau, and Kittson
counties. Wadena, May 4, serving Wadena, Todd, and
Hubbard counties. Moose Lake, May 11 , serving Aitkin,
Carlton, Pine, Mille Lacs, Kanabec, Lake, and Cook
counties. Worthington, May 18, serving Nobles, Jack-
son, Murray, Rock, Pipestone, and Cottonwood counties.
Grand Rapids, May 23, serving Itasca, Koochiching, and
Cass counties. Morris, June 1, serving Stevens, Pope,
Douglas, Grant, Traverse, Bigstone, and Swift counties.
Detroit Lakes, June 8, serving Becker, Clay, and Mah-
nomen counties.

Army Medical Library Consultants
Ask Aid of Medical Men

Hearings in support of a new Army Medical Library
building, suspended during the war, will be resumed in
April before the Budget and Congressional Committees.
These hearings will determine whether a new building
will be erected on Capitol Hill, at a cost of $10 million,
to house the greatest collection of medical books in the
world. It is notable that Dr. William H. Welch called
the Library and its index catalogue America’s greatest
contribution to medical knowledge.

The Library has been reorganized, and it is no longer
possible to carry on in the present building, erected in
1887. The need for the new building has never been
disputed, but the Association of Honorary Consultants
to the Library, of which Dr. John F. Fulton of Yale
University is president, fears that unless the medical
profession rallies to the aid of the project the laws will
not be amended to provide a proper building.

Minneapolis Director of Venereal
Disease Control Wanted

The Minneapolis Civil Service Commission announces
an examination for the position of Director of Venereal
Disease Control, for which applications will be accepted
until April 30. The salary for the full-time position is
$5000. Appointment will be made on a permanent basis.
The residence requirement is waived. A Master of Pub-
lic Health degree or a Certificate of Public Health is
required. For additional information and application
blanks call at Room 109, City Hall.

124

The Journal Lancet

B<mU Reviews

A Mirror for Cure-Takers, edited by Harold Holand.
Milwaukee: Wisconsin Anti-Tuberculosis Association, 1946.
Pp. 184, illustrated. $2.00.

This book, edited by Harold Holand, consists of a fine col-
lection of writings (previously published in sanatorium maga-
zines) of persons who, for the most part, have been treated in
Wisconsin sanatoriums. It is dedicated to Dr. Hoyt E. Dear-
holt, who, from the beginning of this century, was a power in
the control of tuberculosis, not only in Wisconsin, but through-
out the nation. Many of his creations in tuberculosis control,
such as the establishment of sanatoriums in Wisconsin, have
continued since his death in 1939. He was the author of the
famous quotation, "No home is safe from tuberculosis until all
homes are safe.” His greatness was recognized, and after his
death the Mississippi Conference on Tuberculosis established a
Dearholt Medal Award, which is awarded annually to the per-
son who has done the most meritorious work in the field of
tuberculosis.

The book contains articles by and about famous Wisconsin
physicians who have contributed so much to our knowledge of
the disease — Oscar Lotz, W. H. Oatway, R. D. Thompson,
Earl E. Carpenter, and H. A. Anderson. Many other articles
were written by former nonmedical patients, some of whom sub-
sequently made outstanding accomplishments in various walks
of life. One of the outstanding examples is Will Ross, who
gives wholesome advice in articles entitled "The Meaning of
Rest” and "The Cured and Half Cured.” Almost forty years
ago he was desperately ill with tuberculosis. He was compelled
to devote several years of his life to the treatment of this dis-
ease. During the later part of his convalescence he began sell-
ing supplies to fellow patients, and then he opened a little
supply store at the state sanatorium. Now Will Ross, Incor-
porated, is the largest hospital supply house in the Middle
West. His unprecedented success in the business world never
detracted from his interest in the control of tuberculosis. Not
only has he greatly encouraged large numbers of persons suf-
fering from this disease; he has also participated in the rehabili-
tation of a great many tuberculous individuals. His advice has
been constantly sought, not only by the Wisconsin Anti-Tuber-
culosis Association, but also by great national organizations
such as the National Tuberculosis Association. After he had
served on a number of the most important committees of this
organization, he was elected to its presidency in 1945. Through-
out the entire history of this association he is the second lay-
man to be elected to its presidency, Homer Folks of New York
City having been the first, in 1912.

In this book much deserved recognition is given to Dr. T. L.
Harrington, referred to as teacher, doctor, laugh-bringer, and
friend, who began his crusade against tuberculosis in 1903,
and only recently retired at the age of 75 years. Nevertheless,
his interest and effectiveness in tuberculosis control continues.
Only one year ago he contributed an excellent article to the
Journal Lancet.

Harold Holand, a former tuberculous patient and now the
director of the research department of the Wisconsin Anti-
Tuberculosis Association, has contributed effectively to tubercu-
losis control in Wisconsin. The editing of this book is a fine
contribution. The selection of articles from the various sana-
torium magazines required much labor and keen judgment,
which resulted in a volume packed with authentic information,
presented so entertainingly that the reader is disappointed that
it is not longer, and desires to read it again and again.
Although the book is intended primarily for distribution among
Wisconsin sanatorium patients, it should be made available to
all patients Moreover, it can be read with great profit by all
members of sanatorium personnel, as well as by all social work-
ers, nurses, and physicians especially interested in tuberculosis.
— J. A. M.

^becUUd,

Dr. Robert Glenn Allison, 58, radiologist in prac-
tice in Minneapolis since 1920, died March 20, 1946,
at Northwestern Hospital, several hours after he became
ill at his office. Interment was at York, South Carolina,
his birthplace.

Dr. Allison was a graduate of the University of Mary-
land Medical School in 1912, and served as a captain
with the Army Medical Corps in World War I. Before
coming to Minneapolis he served on the staffs of Tru-
deau Sanatorium at Saranac Lake, New York, the Mu-
nicipal Tuberculosis Sanatorium in Chicago, and Harper
Hospital, Detroit. In addition to his private practice,
Dr. Allison was clinical professor of radiology at the
University of Minnesota.

Dr. Charles Edward Blankenhorn, 56, of Great
Falls, Montana, died March 6, 1946, at Boise, following
an illness of nearly three years. Dr. Blankenhorn was
born in L’Anse, Michigan, April 3, 1889. Following
two years at the University of Michigan, he attended
Marquette University, in Milwaukee, and was graduated
from the Medical School in 1913. He later studied in
Rochester (New York), Milwaukee, Chicago, and in
Europe. During World War I he was commissioned
a first lieutenant and went overseas with the 16th am-
bulance corps, 2d division, and was invalided home in
1918.

Following some years of practice in Butte and Malta,
Montana, Dr. Blankenhorn went to Great Falls, where
he practised for twenty years. He was a member of the
Montana State Medical Association and the Cascade
County Medical Society.

Dr. James Watkins Fennell, 60, of Missoula, Mon-
tana, died February 23, 1946, at his home. Dr. Fennell
was born February 18, 1886, in Seguin, Texas, of a line of
physicians. His grandfather, Dr. Thomas Jefferson Fen-
nell, served as a surgeon with the Confederate Army,
and his father was a practising physician in Seguin.

Dr. Fennell had his medical training at Vanderbilt
University, from which he was graduated in 1907. Dur-
ing World War I he served with the Johns Hopkins
unit, and spent 22 months overseas. He held the rank
of major and served in army posts in the states before
being transferred to Honolulu. He made a government
survey in Alaska and served on the medical staff of the
University Hospital in Seattle before coming to Missoula
in 1943 to serve on the medical staff of the Northern
Pacific Hospital, the post he held at the time of his
death.

Dr. C. E. French, 82, Minneapolis, who formerly
practised in Duluth, died March 2, 1946, at the Vet-
erans Hospital, Minneapolis. He was a veteran of the
Spanish-American War.

April, 1946

125

Dr. Stanley Clifford Mulholland, 52, of Santa
Barbara, California, formerly of Minneapolis, died
March 4, 1946. A graduate of the University of Min-
nesota Medical School in 1923, he was associated with
the Physicians’ Clinic of Fort Dodge, Iowa, until 1928,
and then with the Billings Memorial Hospital, Chicago,
and the Rees Staley Clinic, San Diego. He had been a
resident of Santa Barbara for seven years.

Dr. Harold Eugene Robertson, 67, of Rochester,
Minnesota, senior consultant and former head of the
section on pathologic anatomy of the Mayo Clinic, died
March 8, 1946. Born at Waseca, Minnesota, October 8,
1878, he was graduated from Carleton College in 1899
and received his M.D. from the University of Pennsyl-
vania in 1905, and had studied also at the University
of Berlin and the University of Freiberg.

After his early work as an instructor at Albany and
Harvard University and pathologist at Boston City Hos-
pital, he became an instructor in pathology at the Uni-
versity of Minnesota in 1907, where he remained until
1921. Since that year he had been associated with the
Mayo Clinic, and was also professor of pathology of the
Mayo Foundation graduate school of the University.

Dr. Patrick McHugh Walker, 70, of Los Angeles,
died February 25, 1946, in that city. An early resident
of Grafton and St. Thomas, North Dakota, he prac-
tised for a short time at Ellendale and at St. Thomas
from 1901 to 1906. He was chief division surgeon for
the Great Northern Railway for 13 years before he
moved to Pasadena in 1914. Following some years of
retirement, he resumed practice in Los Angeles and con-
tinued until a short time before his death. Dr. Walker
attended Notre Dame University, McGill University,
and the University of Edinburgh, and interned at Guy’s
Hospital, London.

Views Items

NEWS FROM MINNESOTA

University of Minnesota. The thirteenth E. Starr
Judd Lecture will be given at the University of Minne-
sota Monday evening, April 15, by Dr. Samuel C. Har-
vey, William H. Carmalt Professor of Surgery at Yale
University. Subject : "The Healing of the Wound.”
The Judd annual lectureship in surgery was established
by E. Starr Judd, an alumnus of the University of
Minnesota Medical School, a few years before his death.

Dr. Ancel Keys, director of the laboratory of physio-
logical chemistry, and his associates have recently pre-
sented before scientific groups the results of their re-
search on starvation diets. Dr. Keys urges that the
American people decide at once upon some course of
action in feeding gravely undernourished peoples in
many parts of the world, and declares that underfeeding
of these peoples will result in political apathy and in-

ability to appreciate the difference between democratic
and authoritarian forms of government. His research
during the war shows that after partial starvation recov-
ery of full health and working capacity is slow, even on
relatively good diets.

A study of the present situation of more than 40,000
wartime medical officers now discharged has been made
by the Northwestern National Life Insurance Company.
As part of the study an analysis was made of the nearly
200 medical officers now taking postgraduate work in
medicine at the University of Minnesota. It shows that
the "typical” medical veteran-student is 32 years old,
married, and father of one or two children; that he had
completed seven years of advanced education and a
year of internship before entering military service, and
was in service three to five years. The report indicates
also that the civilian shortage of physicians will continue
for some time, owing to the number of returning doctors
who are seeking further training before resuming prac-
tice.

Dr. Robert G. Green and Dr. John Bittner and their
associates have reported before the American Association
for Cancer Research the development of a serum that
will prevent the development of breast cancer in mice
otherwise prone to develop the disease.

Dr. Gaylord Anderson, who has returned to his post
as director of the School of Public Health at the Uni-
versity, is of the opinion that the great volume of data
on health and medical conditions throughout the world
gathered by the medical intelligence service he directed
will be of great value in promoting better health during
peace.

Dr. Richard V. Ebert has been appointed associate
professor of medicine, and will divide his time between
teaching and research.

Dr. Ernest Carroll Faust, professor of parasitology at
Tulane University, spoke before the Minnesota Patho-
logical Society at the Medical School on March 19 on
"Interpretations of Recent Research and Clinical Experi-
ence on Malaria.”

Dr. J. Arthur Myers, speaking at the meeting of the
Missouri Medical Association in St. Louis late in March,
described the new drug streptomycin as offering new
hope for tuberculosis sufferers and said that "we are
apparently much closer to a satisfactory chemotherapeu-
tic agent than ever before.”

Medical social workers attending a conference at the
University of Minnesota center for continuation study
heard several talks on tuberculosis at their final meeting
on March 16. Speakers included Dr. Gaylord W. An-
derson, Dr. Ruth B. Taylor, Dr. E. S. Mariette, super-
intendent of Glen Lake Sanatorium, Dr. John L. Mc-
Kelvey, professor of obstetrics and gynecology, who
spoke on "Tuberculosis in Pregnancy,” and Arthur T.
Laird of Duluth, who spoke on "Tuberculosis in the
Aged.”

126

The Journal Lancet

Speaking before the Institute on Rural Medicine, Dr.
A. W. Adson of the Mayo Clinic gave it as his opinion
that a government administered medical program would
be expensive without any assurance of quality of service,
and that a prepaid medical service operated by the doc-
tors themselves would be more effective.

According to a survey conducted by the National Blue
Cross Commission, Minnesota had fewer cases of pneu-
monia and influenza in the first two months of 1946
than other areas of comparable size in the nation. Ac-
cording to Dr. William A. O’Brien only 5.2 per cent
of patients admitted to Minnesota during this period
had pneumonia or influenza, as compared with a national
average of 9.2 per cent.

The Minnesota Academy of Medicine, meeting at the
Town and Country Club, St. Paul, on March 13, adopt-
ed the Articles of Incorporation of the Academy and
heard Dr. J. A. Lepak report on a case of multiple
myeloma and Dr. Martin Nordland report on a case
of cancer of the duodenum and a case of islet tumor
of the pancreas.

Speakers at the regional conference for public health
nursing service held at Little Falls on March 29 included
Dr. R. N. Barr, Dr. Vern D. Irwin, and Dr. Viktor
Wilson.

Dr. E. S. Palmerton has resumed practice at the
Gamble Clinic, Albert Lea, after 3 /i years in the Army
Medical Corps.

Dr. M. J. Grogan will become resident physician at
Ceylon, which has been without a doctor since Dr.
I. Fisher moved to St. Paul.

Nobles County is holding 1 1 immunization clinics,
and Murray County one, during April. The clinics are
primarily for school children.

Dr. Gordon Paulson, assigned to a large general hos-
pital in Rome, talked by transatlantic telephone with his
father, Dr. T. S. Paulson, of Fergus Falls, on March 2.

Prepaid medical service program for Minnesota. Fol-
lowing passage of state legislation permitting the forma-
tion of such a service, a committee of 23 doctors met in
Minneapolis March 1 to plan a nonprofit prepaid med-
ical service program for Minnesota. The committee, ap-
pointed by the house of delegates of the Minnesota State
Medical Association, has Dr. B. J. Branton of Willmar
as chairman and Dr. M. W. Weaver, assistant dean,
University of Minnesota Medical School, as secretary.
The medical service will be extended in conjunction with
existing prepaid hospital service plans, according to Dr.
A. W. Adson of the Mayo Clinic, and will enable rural
groups, employed groups, and individuals to have pre-
paid medical service. The plan will be submitted for
the approval of the Minnesota State Medical Associa-
tion at its annual meeting on May 20.

The blind prefer medical treatment from physicians
familiar to them. The report of a survey group of the
Minneapolis Council of Social Agencies who studied 210
sightless persons, ranging in age from 10 to 95, makes

a number of points concerning their preferences and
characteristics. It was found that the sightless are re-
luctant to receive treatment from physicians with whom
they are not acquainted, and hence to accept public med-
ical care; that "an overwhelming majority . . . believe
the possibility of improvement in their condition to be
unlikely”; that the blind as a group are more subject
to other ailments than the population as a whole, with
only 57 persons, or 37.2 per cent, in average health or
better. (It is noted that the majority of visually handi-
capped persons fall into the age group most likely to
suffer chronic illness.) However, in spite of this in-
creased susceptibility to illness, more than 90 per cent
of the employed were found to have attendance records
as good as or better than other employees.

Medical social workers needed. Minnesota social and
medical agencies are conducting a campaign to aid in
recruiting more candidates for medical social training.
Such workers are needed by veterans’ hospitals, clinics,
and public and private hospitals, as well as by social
agencies.

Cancer education and progress. During March and
April a poster and essay contest for Minnesota high
school students is being held under the sponsorship of
the Minnesota Cancer Society, of which Dr. William
A. O’Brien is chairman, and the Women’s Auxiliary
of the Minnesota State Medical Association. State chair-
man of the contest is Mrs. Harold Wahlquist, 129 W.
48th Street, Minneapolis.

A two-day institute on cancer education was held in
Duluth March 12-14. Dr. F. H. Magney of Duluth
presided and Dr. W. A. O’Brien spoke on "The Na-
ture of Cancer.”

New members of the Board of Directors of the Min-
nesota Cancer Society include Dr. Charles Mayo, Roches-
ter, Dr. Wilhelm Stenstrom, University of Minnesota,
and Dr. Henry B. Clark, Sr., St. Paul.

The annual fund raising campaign of the Minnesota
Cancer Society will be conducted during April. Five
objectives have been set up by the society for the cur-
rent year: examination centers, more modern X-ray

equipment and more radium, more hospital provision for
cancer patients, education of the public concerning the
danger signals and necessity for early diagnosis and treat-
ment of cancer, and visiting nurse service for cancer
patients. The plan is to organize cancer detection cen-
ters in hospitals throughout the state to facilitate early
diagnosis and treatment of the disease. Examinations
would be given without charge at hospitals approved by
the American College of Surgeons. The first centers
would be set up in Minneapolis, St. Paul, and Duluth,
according to the suggested plan. The Duluth center
will be opened the second week in April at Miller Mem-
orial Hospital, according to Dr. M. G. Fredricks, chair-
man of the committee on cancer of the St. Louis County
Medical Society.

Minnesota’s share of the $12 million set as the nation-
wide goal by the American Cancer Society is $224,000.
Of the funds raised in Minnesota, 60 per cent will be

April, 1946

127

used for state projects and 40 per cent by the American
Cancer Society for research. O. J. Arnold is the state
chairman of the fund-raising campaign for Minnesota.

Dr. Dewey Edison Morehead is in Peru, where he
will deliver a paper on "Surgery of the Acute Gall-
bladder” before the College of Surgeons.

Graduates of the Medical School of the University
of Minnesota in March included Hershel Boyd Cope
and Frank McIntyre MacDonald of Virginia, Minne-
sota, and Robert V. Hodapp of Willmar, all of whom
received the degree of Bachelor of Medicine.

NEWS FROM MONTANA

A five-county meeting was held at Bozeman in March
to discuss the district hospital organization plan. Dr.
Herbert Wagner of the U. S. Public Health Service
was the principal speaker. Also present was Edwin
Grafton, Helena, president of the Montana Hospital
Association.

Dr. Anthony J. J. Rourke, physician superintendent
of Stanford University Hospital, San Francisco, has
been engaged by the Memorial Hospital Association of
western Montana to conduct a hospital survey of West-
ern Montana hospital needs.

Dr. H. L. Casebeer, Butte, was elected president of
the Montana Academy of Otolaryngology at a meeting
of the group held in Billings late in February. Dr. Fritz
Hurd, Great Falls, was named secretary-treasurer. The
principal talk at the annual meeting was given by Dr.
J. Calvin Davis of the University of Nebraska.

Dr. F. L. Andrews of Great Falls has announced his
retirement on March 1 after 28 years of practice as a
physician and surgeon in that city. Dr. Andrews, a
native of North Anson, Maine, studied at the University
of Iowa and the Chicago College of Medicine and Sur-
gery. Before coming to Great Falls Dr. Andrews was
resident surgeon at St. Luke’s Hospital, Cleveland, and
surgeon with Evacuation Hospital No. 12 in France and
Germany during World War I. During his first 18
years in Great Falls Dr. Andrews practised in partner-
ship with Dr. Edward F. Keenan. Dr. and Mrs. An-
drews will travel following his retirement.

Dr. B. K. Kilbourne, Helena, has been appointed
executive officer of the Montana State Board of Health,
succeeding Dr. W. F. Cogswell, who retires on April 1.
Dr. Kilbourne came to Montana in 1935 as state epi-
demiologist.

The Livingston Clinic will be opened in Livingston on
April 1, in the Gamier Building, by Dr. W. E. Harris,
Dr. R. E. Walker, and Dr. W. Cloyd, all recently re-
leased from Army service. Dr. Harris has been appoint-
ed senior physician and surgeon for the Northern Pa-
cific Railroad in Livingston, succeeding the late Dr.
Paul L. Greene.

A special meeting of the House of Delegates of the
Montana State Medical Association was held in Helena
on March 10, to continue discussion of the organization

of the Montana Physicians’ Service. Mr. Sam English
of California has been engaged as executive director of
the service.

Resuming practice. Dr. D. N. Monserrate will re-
open private offices for the practice of medicine and sur-
gery in Helena after service with the Army Medical
Corps. Dr. F. W. Waniata has resumed practice in
Great Falls with the North Montana Clinic after 26
months’ service with the Army Medical Corps which
took him to England, where he was in charge of gen-
eral surgery at a general hospital. Dr. William Mor-
rison has resumed his position as assistant chief surgeon
at the Northern Pacific Hospital in Missoula after serv-
ing as a lieutenant commander in the Navy, during
which he saw service in the Pacific. Dr. John F. Mc-
Gregor has resumed practice with his father, Dr. Harry
J. McGregor, and his brother, Dr. Robert J. McGregor,
at their clinic in Great Falls, following nearly two years
of service in the European Theater. He was a lieutenant
colonel at the time of his release.

NEWS FROM NORTH DAKOTA

Dr. A. H. Reiswig of Wahpeton is attending a post-
graduate course in surgery at George Washington Uni-
versity.

Dr. B. J. Branton of Willmar, Minnesota, chairman
of the committee on prepaid medical care of the Minne-
sota State Medical Association, spoke March 21 at
Minot on voluntary medical prepayment plans for low-
income groups at a public meeting sponsored by the
Northwestern District Medical Society.

Dr. J. J. Korwin of Williston spoke March 19 at a
meeting of the Williams County Health Advisory Coun-
cil, in celebration of the acquisition of an audiometer,
paid for through the donations of many local groups.

Dr. Bruce Boynton is beginning practice in Park River
in association with Dr. F. E. Weed. He is a graduate
of the University of Minnesota Medical School and
interned at St. Mary’s Hospital, Duluth.

Dr. W. J. Houza has arrived in Mandan to practice
medicine in association with Drs. Hetzler and Wheeler.
Dr. Houza was overseas in the South Pacific for 20
months with the 4th Marine Division.

The North Dakota State Medical Center, to be
established at the University of North Dakota, has re-
ceived a contribution of $10,000 from the Myra Foun-
dation of Grand Forks, to be used in surveying the
problem of the center and preparing plans and specifica-
tions for the final project. The contribution will enable
the newly created center to employ a full-time director
to present the project to the public and further its cause
before the legislature and foundations and other groups
or persons likely to aid in the advancement of the work.

Dr. Charles W. Bums of Winnipeg addressed the
District Medical Society at Grand Forks on March 20,
on "Diseases of the Large Intestine.”

Dr. J. M. Muus has begun practice at the McVille
Community Hospital, reopened in March. Dr. Muus,

128

The Journal Lancet

a graduate of Temple University School of Medicine
who interned at Henry Ford Hospital, has been dis-
charged from the Army Medical Corps following two
years of service, including 1 1 months in England with
the 107th General Hospital. The McVille Journal ob-
serves that the "community extends a friendly and neigh-
borly hand in welcoming Dr. and Mrs. Muus.”

Crowded conditions in St. Alexius Hospital, Bismarck,
are depicted graphically in photographs published in the
Bismarck Tribune of March 19, showing the hospital
parlor converted into a maternity ward accommodating
seven patients and children in the pediatrics department
cared for in the hospital hall.

Hattie L. Clune, R.N., of Hibbing, Minnesota, has
been appointed a special consultant in connection with
the inspection of hospitals and maternity homes in North
Dakota.

New M.D.’s. Robert Nelson Webster of Northwood,
graduate of Washington University Medical School.
Donald Strand, formerly of Mandan, graduate of Tem-
ple University School of Medicine.

NEWS FROM SOUTH DAKOTA

Shortage of doctors in South Dakota continues. Dr.
Gilbert Cottam, superintendent of the State Board of
Health, is of the opinion that the shortage of physicians
in the state may continue for years. A map in his of-
fice, marked with pins to show the location of physi-
cians, illustrates the situation. The 590,000 residents of
the state are served by 342 physicians, one third of whom
are over 65 years of age. Many are handicapped by
physical ailments. The map shows also that the doctors
are concentrated in the larger cities, and that hundreds
of square miles of the rural areas are doctorless. Sioux
Falls, Aberdeen, and Rapid City have 80 physicians, but
many of them are specialists, with limited practice.

According to Dr. Cottam, the decrease in doctors
began during the drought years and reached a climax
during the war. Dr. Cottam points out that men just
out of medical school are reluctant to locate in small
towns for several reasons, among them the necessity of
heavy expenditure to buy equipment available to them
without cost in city medical centers. "Many,” he re-
marks, "have had training in specialized fields, and for
them the smaller places can offer no opportunity. Quali-
fied general practitioners are needed most, and these are
becoming scarce.”

There is also a shortage of nurses and hospitals, but
Dr. Cottam remarks that "to build a hospital in a com-
munity where there is no doctor will not necessarily
attract one, because hospitals have closed in several com-
munities and no doctors are available.” He believes,
however, that construction of new hospitals planned for
more than a dozen communities in South Dakota in the
near future will definitely reduce the hazard of improper
medical care in the state. A state-wide survey of hospital
needs is being made by the State Health Department
and the State Health Committee. There are now 52 hos-
pitals in the state, not including maternity homes.

Dr. Theodore Foster Riggs of Pierre has been honored
with an honorary LL.D. degree by Beloit College in
recognition of his role in bringing modern medical serv-
ice to South Dakota’s range country. Dr. Riggs, a grad-
uate of Beloit College and Johns Hopkins University
School of Medicine, began practice at Pierre in 1908
and is credited with modernizing St. Mary’s Hospital
there. He established the Pierre Clinic 25 years ago.

Deadwood hospital project. Dr. F. S. Howe, presi-
dent-elect of the South Dakota Medical Association,
spoke before the Deadwood Chamber of Commerce at
the regular Tuesday meeting on March 5, concerning
the work of the hospital committee and progress in the
campaign to build a modern 100-bed hospital for Dead-
wood. Dr. Howe described the critical situation brought
about by the lack of doctors and facilities throughout
the state and said that the only solution is to concen-
trate facilities and available physicians in locations most
convenient to the large number of people to be served.
A committee of 25 members has been appointed to pro-
mote the project.

Burke hospital project. Reports on current progress
in the new hospital building program were presented
March 5 at the annual meeting of the Community Mem-
orial Hospital, Inc.

Dr. Peter K. Steiner, formerly of Yankton, will be
associated with Dr. F. C. Totten at Lemmon, beginning
April 1.

Dr. Samuel Schultz of Philip has been asked by
local businessmen to reconsider his decision to leave.
Plans are being made to renew the campaign for contri-
butions to the hospital fund.

Dr. John B. Janis, physician and surgeon of Cam-
bridge Springs, Pennsylvania, plans to move to Hoven
as staff physician of the local hospital.

Members of a committee promoting the cause of estab-
lishing the Clark County Memorial Hospital are visiting
neighboring communities to give authentic information
concerning the project. Some $7,000, representing the
donations of 46 persons, have been pledged.

Dr. E. T. Plowman, formerly of the Mesaba Clinic
at Marble, Minnesota, has joined the staff of the Wat-
son Clinic at Brookings, according to an announcement
made by Dr. E. Sheldon Watson, head of the clinic.

Dr. C. S. Moran has begun medical practice in
Mitchell in association with the Drs. Frank and Leonard
Tobin.

Dr. Lloyd Cramer has been made chief medical officer
at Battle Mountain Veterans Facility, succeeding Dr. F.
W. Ogg, who has been assigned to a post in the Vet-
erans Administration in Washington.

Dr. Maurice C. Rousseau is on terminal leave from
the Army Medical Corps and plans to resume his prac-
tice in Watertown in association with Dr. H. Russell
Brown.

Dr. W. A. Miller, son of W. C. Miller of Selby, has
formed a new medical partnership at Aledo, Illinois,
with Dr. L. E. Robinson, who recently returned after
service with the Army Medical Corps, in which he held
the rank of colonel.

April, 1946

129

LATE NEWS ITEMS

The Minnesota state supervisor of old age assistance,
John Poor, sp>eaking before those attending a continua-
tion course in medical social service at the university,
stated that Minnesota has a liberal program for helping
recipients of old age assistance to pay for medical care.
The law adopted by the last legislature permits the state
and county to pay jointly medical expenses in excess of
the normal $40 a month maximum. Payments for in-
dividual care vary from slightly over $40 to as high as
$559 a month, with an average of $65. The program
has cost about $72,000 a month to date.

Mayo Clinic. Dr. Albert M. Snell of the teaching
staff of the Mayo Foundation has been named chief of
the gastro-enterology section and Dr. Ralph Gormley
head of the orthopedic section of the professional serv-
ices division of the Veterans Administration.

Dr. John L. Emmett, consultant in urology, spoke on
"The Surgical Management of Cord Bladder” before
the 10th Annual Meeting of the American Urological
Association, Southeastern Section, held at Augusta,
Georgia, in March.

Drs. H. W. Schmidt, Edward B. Tuohy, and Charles
F. Stroebel of the Mayo Clinic staff have been released
from Army service.

Dr. Charles Anderson of Duluth, recently discharged
from the Army Medical Corps after four years of serv-
ice, has joined the staff of the Shipman Hospital.

Dr. E. N. Milhaupt, eye, ear, nose, and throat spe-
cialist, formerly of Toledo, Milwaukee, and Minneapolis,
will be associated in practice with Dr. W. T. Wenner
in St. Cloud.

Dr. Stanley T. Kucera of the Northfield Hospital
staff announces plans for a new building in Northfield,
to include offices, apartments, and shops, as well as a
large medical suite where he will be associated with Dr.
A. M. Nielsen.

Dr. John E. Crewe, coroner of Olmsted County for
36 years, has announced his retirement, owing to illness.

Dr. Bertram Adams of Hibbing spoke on socialized
medicine March 19 before the Hibbing Chamber of
Commerce. He noted that the prepayment plan of med-
ical care used on the iron range for many years has been
successful and spoke with approval of the Michigan
plan.

Dr. R. B. J. Schoch, St. Paul city health officer,
has recommended immediate removal of the city health
bureau to Ancker Hospital from its present quarters in
the workhouse.

Dr. Arrah B. Evarts of Rochester spoke on "A Re-
view of Early American Medicine” at a meeting of the
Rochester chapter of the D.A.R. on March 15.

County Officers Meeting. Speakers at the meeting for
officers of 34 county and district medical societies, held
in Minneapolis March 2, included Dr. A. J. Chesley,
Dr. A. W. Adson, Carl D. Hibbard, Dr. John R.
Paine, Dr. Arthur W. Wells, and Dr. Richard B.
Hullsiek. Medical care for returned servicemen, the

state hospital survey, and the organization of cancer de-
tection centers were among the topics discussed.

Dr. C. L. Oppegaard of Crookston attended the coun-
ty officers meeting of the Minnesota State Medical Asso-
ciation in Minneapolis on March 2 as representative of
the Red River Valley Medical Society.

Dr. A. J. Chesley, Secretary of the State Board of
Health, and Miss Ann Nyquist, head of the Division
of Public Health Nursing, spent two or three days in
the Bemidji area early in March, checking on the results
of mass chest X-raying carried on with the Hennepin
County Mobile Unit and with the aid of donations of
Bemidji civic groups. Since the survey closed 35 Indians
have entered tuberculosis sanatoriums.

Dr. Roland E. Nutting, Duluth, has been appointed
state chairman of the American Academy of Pediatrics
for Minnesota, succeeding Dr. Roger L. Kennedy of
the Mayo Clinic.

Dr. Wallace E. Harrell, Rochester, discussed "Chemo-
therapy in Prevention and Treatment of Infection” be-
fore the Hennepin County Medical Society on March 4.

V A needs more doctors. There is an emergency need
for many more doctors in Branch 8 of the Veterans
Administration, according to E. R. Benke, deputy ad-
ministrator. Of the five states comprising Branch 8 —
Minnesota, North and South Dakota, Iowa, and Ne-
braska— only Minnesota has a sufficient medical staff,
thanks, the administrator noted, to the co-operation of
the University of Minnesota and the Mayo Clinic.

Dr. A. H. Wolf, formerly of Minneapolis, and re-
cently discharged from the Army, has assumed the prac-
tice of Dr. C. M. Tierney at Harmony. Dr. Tierney,
in terminating his service, "winds up forty years of faith-
ful service to the people of this area,” according to the
Harmony News.

Clinics in which children could be inoculated against
diphtheria were held in 59 public and parochial schools
of Minneapolis during the week of March 11.

New officers of the Montana State Board of Medical
Examiners are Dr. J. H. Garberson, Miles City, Presi-
dent; Dr. P. E. Kane, Butte, Vice President, and Dr.
O. G. Klein, Helena, Secretary (re-elected).

The Southeastern Montana Medical Society met April
8 at Miles City, with 18 present. Samuel English, Exec-
utive Director of the Montana Physicians’ Service, ex-
plained the organization of the service, which will pro-
vide prepaid medical care to Montana citizens. The fol-
lowing officers were elected: President, Dr. J. R. Thomp-
son, Miles City; Vice President, Dr. R. D. Harper, Sid-
ney; Secretary-Treasurer, Dr. Elna M. Howard, Miles
City; delegates to State Association, Dr. J. H. Garber-
son, Dr. M. A. Shillington, and Dr. B. R. Tarbox.

A testimonial dinner for Dr. W. F. Cogswell was
held March 27 in Helena, Montana. Dr. W. F. Cogs-
well is retiring as secretary of the State Board of Health
after 33 years of service.

130

The Journal Lancet

The Minnesota Academy of Medicine held its regular
meeting at the Town and Country Club, St. Paul, on
April 10. Dinner was followed by an organizational
meeting and election of members and a thesis paper by
Dr. N. Logan Leven on the subject "Congenital Atresia
of the Esophagus with Tracheo-esophageal Fistula-Sur-
gical Treatment.”

The American Pharmaceutical Association has award-
ed the 1945 Ebert Prize to Dr. Paul Jannke of the
University of Nebraska College of Pharmacy for his
research on the sclerosing agent, sodium morrhuate. The
investigations are expected to be of value in treating
varicose veins. Dr. Jannke’s experiments showed that
the more nearly saturated fatty acids of cod-liver oil are
the most satisfactory sclerosing agents. Presentation of
the medal will be made at the 1946 convention in
August.

Dr. A. L. Lips and Dr. J. L. Verschure of the Neth-
erlands have been visiting the United States to study
recent medical advances, visit the most important med-
ical centers, and purchase medical books, instruments,
and equipment for Netherlands hospitals and doctors.
Among the medical inventions developed in the Neth-
erlands during the war years, in the face of technical
obstacles and constant interference from the Germans,
is an "artificial kidney” perfected by Dr. Kolff of Kam-
pen. The device, which Dr. Lips and Dr. Verschure
will demonstrate to medical audiences in the United
States, drains and cleans toxic blood and returns it puri-
fied to the blood stream. Other Dutch physicians have
perfected a glass cabinet in which metabolism tests are
given without the use of uncomfortable breathing appa-
ratus. Dr. Lips and Dr. Verschure, both specialists in
internal diseases, are natives of Nijmegen and studied
at Utrecht University.

Dr. Harrison S. Collisi, formerly a colonel in the
U. S. Army, has been named medical director of the
Planned Parenthood Federation of America, succeeding
the late Dr. Claude C. Pierce. Dr. Collisi, a graduate of
the University of Michigan Medical School, was chief
of staff of the Butterworth Hospital, Grand Rapids,
before the war.

An expansion program for the Chicago campus of
Northwestern University which the university hopes to
realize within the next 25 years has been announced.
Broadest in scope among the new developments will
be a medical center that will place major emphasis on
research. Ten new buildings are envisaged which, to-
gether with equipment and endowment for fellowships,
libraries, the publication of research, and a staff of med-
ical investigators, will require a sum ranging from $63
to $95 million. The major project will be an Institute
for Medical Research that will undertake investigation
into the many unsolved problems of medicine, especially
in the field of the degenerative diseases, such as heart
ailments, cancer, high blood pressure, and kidney dis-
orders, incident to adulthood and old age.

Dr. G. Foard McGinnes, medical director of the
American Red Cross, has been named vice chairman
in charge of the newly-established Office for Health
Services. The new office will group together all Red
Cross services relating to health and medical activities,
including the office of the medical director, the nursing,
nutrition, and disaster medical services, and first aid,
water safety, and accident prevention. Before coming
to Washington in October 1943 Dr. McGinnes had been
medical director of the Red Cross midwestern area office
in St. Louis.

FURTHER ANNOUNCEMENTS
Regional Conference on Industrial Health,
Denver, June 4, 1946

The Council on Industrial Health of the American
Medical Association announces a regional conference on
industrial health to be held at the Shirley-Savoy Hotel
in Denver, Colorado, on June 4. Medical men and
community leaders from Colorado, Kansas, Montana,
Nebraska, New Mexico, North Dakota, South Dakota,
Utah, and Wyoming are expected to be present. Dr.
A. J. Lanza and Dr. J. G. Townsend will preside. Panel
discussions on "Industry Needs Medicine” and "Re-
habilitation and Re-employment of the Veteran and Dis-
abled Civilian” are scheduled.

Refresher Course in Otolaryngology and
Course in Broncho-Esophagology

The University of Illinois College of Medicine an-
nounces a one-week didactic and clinical refresher course
in otolaryngology, to be held May 13-18, inclusive, and
a special course in broncho-esophagology, to be given
June 3-15, inclusive. For information address: Depart-
ment of Otolaryngology, University of Illinois College
of Medicine, 1853 West Polk Street, Chicago.

POPULATION TRENDS

The Census Bureau reports that the population of the
United States has risen to 140,000,000, an increase of
8,303,275 in the past five and a half years. In view of
the wartime increase the Bureau, which had estimated
earlier that the growth of population would cease about
1990, is considering whether the recent increase will
have a permanent effect upon population growth in this
country.

Comparative data show that for Russia the birth rate
in the first nine months of 1945 increased over one third
of the same period of 1944. The total population in
1939 (most recent census) was 183,736,286. Recent fig-
ures for France show a population of 40,300,000, a de-
crease of nearly one and a quarter millions since the war
began in 1939. Recent figures from Germany indicate
that the birth rate has dropped sharply and infant mor-
tality has increased. In England a sample census of mar-
ried women will soon be taken to determine the present
population situation. Economic and social pressures,
rather than a decline in general fertility, are believed to
be the cause of the reduction in the birth rate. — Con-
densed from Human Fertility , December, 1945.

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locate in White River, S. Dak. This is an ideal location
for a man that likes the range country; in the center of
an area that does not have adequate medical service;
opportunity to build up a splendid paying practice;
assured of community backing; County Seat of Mellette
County. Write or wire, C. J. Patnoe, President Commer-
cial Club, White River, S. Dak.

FOR SALE

Westinghouse 100 M.A. x-ray; automatic built-in
bucky table. All new equipment used one year. A No. 1
outfit. Now in southern Minnesota. Address Box 83 2,
in care of this office.

ASSISTANCE AVAILABLE

Aznoe’s, established in 1896, has available a number
of well trained physicians (diplomates of the specialty
boards, industrial physicians and surgeons, general prac-
titioners, psychiatrists, tuberculosis specialists and resi-
dents). For histories, write Ann Woodward, Aznoe’s-
Woodward Medical Personnel Bureau, 30 North Michi-
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FOR RENT

Attractive, modern ground floor office in Midway dis-
trict between Twin Cities (Snelling Ave. near Minne-
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Call NEstor 6710 or address Box 837, care of this office.

PRACTICE FOR SALE

North Dakota physician retiring after 39 years in
same town wishes to sell practice and office equipment.
Only physician in presently booming town of 1350
located on main line of Northern Pacific. Extensive
territory, good roads. Home suitable for office and resi-
dence also for sale. Address Box 838, care of this office.

WANTED

More news from district medical society secretaries. If
something of medical interest happens in your bailiwick;
if you have a meeting; if you have personal items about
yourself or fellow members that would be of interest; if
you encounter any unusual development in clinical pro-
cedure or research; and, above all, if you have, listen to,
or hear of a professional paper of excellence: — "write
it in,” in your own words. Our editorial people will do
the rest. — (Ed. Journal Lancet.)

Adue^iUe^s' AtoMUHcetnewk

ALSIGEL and HYPERACIDITY

Alsigel, newly introduced antacid and adsorbent, is an aque-
ous suspension of aluminum hydroxide and magnesium trisili-
cate, in a bulk producing gel.

Into the gastrointestinal situation prodromal to ulcer, Alsigel
introduces a compound of three powerful actions essential to
symptomatic relief and the circumvention of ulcer. Not only is
Alsigel antacid without disturbing peptic digestion, but to areas
of ischemic mucosa or actual ulcer it is a soothing demulcent.
Alsigel synchronizes the behavior of its two ingredients and
obtains maximum gastrointestinal benefit without side effects.

Kunze & Beyersdorf, Inc., Milwaukee, will gladly forward
literature and samples of Alsigel on request.

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THE VALUE OF
KNOX GELATINE
IN PEPTIC ULCER
MANAGEMENT

Many physicians are finding Knox Gelatine a practical aid
in the frequent between -meal feedings that are so often
desirable in the management of peptic ulcer.

Given at hourly intervals, Knox Gelatine provides a satis-
factory control of the gastric secretions and brings relief
from the painful symptoms.

Also, many physicians regularly prescribe the Special Ulcer
Diet described in the Knox booklet, “Peptic Ulcer Dietary.”
This is a complete diet. .. bland, and liberal in calories and
protein. We will be happy to send you as many copies as
you wish.

For the free Peptic Ulcer Dietary... and any of the other
dietaries listed here . . . address your request to Knox Gela-
tine, Box 403, Johnstown, N. Y.

Peptic Ulcer Dietary Diabetic Diets

Knox Gelatine Drink Infant Feeding

Feeding Sick Patients Reducing Diets and Recipes

Protein Value of Plain, Unflavored Gelatine

KNOX GELATINE

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Knox Products Keep Pace Through Laboratory and Clinical Research

SHARP & DOHME ANNOUNCES FOUR
RESEARCH GRANTS

Research grants, totalling #14,400, to support clinical work
in four university medical schools, are announced by Sharp &
Dohme, Inc., Philadelphia. A grant of #5,000 was made to the
Department of Gynecology, Tulane University, New Orleane,
La., in support of clinical research conducted by Dr. C. Gordon
Johnson and a #2,200 grant was directed to Columbia Univer-
sity, College of Physicians and Surgeons, New York City, in
support of Dr. Erwin Brand’s work on proteins and amino acids.

A grant of #6,000 renewed for the University of Illinois,
Urbana, Illinois, in support of the laboratory and clinical
studies of Dr. M. H. Streicher. Also renewed was a #1200
grant to the Mendel Research Fund, Yale University, New
Haven, Conn., in support of clinical work conducted by the
Department of Physiological Chemistry.

COMMERCIAL SOLVENTS APPOINTS DR. SMITH

Lawrence W. Smith, M.D., well-known pathologist, is now
associated with Commercial Solvents Corporation as Medical
Director.

Previously, Dr. Smith was Professor of Pathology at Temple
University School of Medicine and was Director of Laboratories
at Temple University Hospital. He also worked extensively
with the Lakeland Foundation on the development of thera-
peutic uses for chlorophyll and its derivatives in the cure of
war wounds and burns.

Dr. Smith became instructor in pathology at Harvard Uni-
versity in 1920. In 1922 he went to the University of the
Philippines at Manila as Professor of Pathology and Bacteriol-
ogy. He returned to Harvard the following year as faculty
instructor in pathology; he became Assistant Professor in 1926.
In 1928 he joined the staff of Cornell University’s Medical
College, and was made Associate Professor in 1932.

Influenza Virus Vaccine, Types A and B,
Calcium Phosphate Adsorbed (Refined and Concentrated)

A new vaccine containing calcium phosphate-adsorbed virus
has been obtained from the allantoic fluid of virus inoculated
embryonated hens’ eggs. Each cc. of the vaccine contains 0.5 cc.
of type A and 0.5 cc. of type B virus inactivated with formalin.
Its use is for prophylaxis against epidemic influenza due to
types A and B influenza virus. It will be supplied in 5-cc.
(five-dose) rubber-diaphragm-capped vials. The manufacturer
is Parke, Davis 8t Company, Detroit 32, Michigan.

DR. LARKUM WITH AMES COMPANY

The appointment of Newton W. Larkum, M.D., as Medical
Director of Ames Company, Inc., has been announced by
Charles F. Miles, Vice-President.

Dr. Larkum comes to the Ames Company, Inc., from the
Army Medical Corps which he entered in May, 1941, as
Major in the Sanitary Corps, and was transferred to the Med-
ical Corps in May, 1942. He was promoted to Lt. Col. in
October, 1942. Dr. Larkum was in the Division of Bacteriol-
ogy May to November, 1941; Chief Division of Bacteriology,
November 1941 to 1943; Chief of Laboratory Service, 100th
General Hospital, November 1943 to June 1945; assigned as
pathologist, Veterans Administration, Hines, Illinois, August
1945; and a graduate of School of Tropical Medicine, Army
Medical School, March 1944.

The fields of research, teaching and administration have given
him quite a varied line of experience before his army services.
He is a graduate of Bates College; received his Ph.D. Degree
at Yale University and his Medical Degree at the University
of Virginia; is a Fellow of American Public Health Assn.; a
Member of the Society of Experimental Biology and Medicine;
and the Michigan Pathological Assn.

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SPECIAL PEDIATRICS NUMBER
Erling S. Platou, M.D., Editor

Dedicated to the memory of Dr. Chester A. Stewart,
1890-1946

It is indeed fitting that the application of new developments in the field of
child health should be keynoted in this issue of Journal Lancet memorializing the
life of Dr. Chester A. Stewart, for he took a keen interest in applying new knowl-
edge and speculating on even greater possibilities in a wide field of medicine.
Well grounded and always abreast of the times, he was able to bring to the stu-
dent and practitioner a stimulating, practical, and comprehensive exposition of
clinical pediatrics.

Dr. Stewart’s constant interest in all aspects of the health of children seemed
to broaden our vision of the field, which we now begin to understand more clearly.
We may hope that with this greater understanding we shall be able to make greater
use of preventive and therapeutic measures in promoting the health of children.
The establishment and maintenance of the physical and mental well-being of this
age group are perhaps the greatest contribution that can be made toward a future
world at peace.

Special pediatrics numbers of the Journal Lancet were inaugurated by Dr.
Stewart and ably edited by him for many years. All of us concerned with this
issue hope that it at least approaches the high standard of pediatrics literature
with which he was identified. It is with profound respect that we dedicate this
special number to his memory.

E.S.P.

132

The Journal Lancet

Chester Arthur Stewart -Physician, Teacher, Clinical
Investigator, Organizer, and Friend of Man

A Personal Appreciation

J. Arthur Myers, M.D.

On November 6, 1890, an infant was born in Han-
nibal, Missouri, who was destined to contribute
mightily to the welfare of infants and children every-
where. His parents, Robert Henry and Lorraine Sanner
Stewart, named him Chester Arthur.

Hannibal, a small city nestled in the hills of Missouri
on the banks of the Mississippi, had already been made
famous by at least one of its residents, Mark Twain.
It was a good place for a human mind to develop and
to become conscious of the world. With his playmates
Chester built rafts, fished, observed the river boats and
the operations of the railroads, saw the horse and mule
give way to motor-driven vehicles, watched the circus
trains unload and followed along with the parade, took
hikes over the surrounding countryside and became
familiar with the flora and fauna, saw how human food
is produced and distributed, participated in such games
as baseball, and even did a little skating and coasting.
These and a hundred other activities provided the boy
with an education not obtainable from books.

Hannibal had a good school system where, in due
time, Chester began his formal education. When he
was fourteen years of age and in the eighth grade, his
father died from rheumatic fever. Chester then assumed
considerable responsibility for his brothers, Rollo and
Benjamin, eleven and eight years old, respectively, as
well as the support of his mother. At this early age he
accepted any kind of work available outside of school
hours; frequently he began delivering papers shortly
after two in the morning.

While in high school Chester procured a clarinet and
joined the Hannibal band, and at times he and other
members engaged in Chautauqua work. Toward the end
of a strenuous day of handling bags of cement in the
freight yards, this high school boy decided he could
probably contribute more to the world if his formal edu-
cation were continued, and he decided to go to college,
despite the fact that he must earn his way and aid the
family at home.

He chose the University of Missouri, and on arrival
in Columbia procured work as a waiter in a boarding
club. This work, together with odd jobs, enabled him
to matriculate and remain in school. As a clarinetist he
was soon in demand in music circles, and this skill added
greatly to his financial support.

In 1913, while a temporary instructor in anatomy at
the University of Missouri, I met Chester Stewart, then
a sophomore student in medicine. He was held in high
regard by faculty and students alike, because of his
scholastic attainments, his complete trustworthiness, and
the fact that he was working his way through school.
When I left Missouri in June 1914, Chester’s plans were

Dr. Chester A. Stewart

unknown to me. In September of that year, on arrival
in Minneapolis, my family took a room near the campus
while seeking permanent quarters. The following morn-
ing it was a delightful surprise to spy Chester and a
young lady strolling by. We beckoned to them and
learned that until a few days before the young lady had
been Miss Dorothy Huffman of Nevada, Missouri.
They also were looking for living quarters. This encoun-
ter was the beginning of a most beautiful and lasting
family friendship.

Chester had accepted the Shevlin Fellowship at the
University of Minnesota, under the directorship of the
famous anatomist, C. M. Jackson. We were directed to
the Institute of Anatomy, where Dr. Jackson assigned
us as office partners. In the department we taught the
various branches of anatomy, including gross dissection,
histology, neurology, and embryology, in association with
persons destined to become famous, such as Richard E.
Scammon and A. T. Rasmussen. From the numerous
research projects suggested by Dr. Jackson, Chester
chose the subject of inanition, which involved a tremen-

May, 1946

133

dous amount of experimental investigation on white rats.
Since Chester was so faithful and trustworthy, Dr. Jack-
son gave him full responsibility for the large animal
colony, where other faculty members and students were
conducting investigations. The extensive and intensive
studies on the effects of inanition on the growth and de-
velopment of various organs gave him a vantage point
as knowledge of the vitamins unfolded, and when he
later devoted so much time to the diets of infants and
children. During 1917 he was instructor in anatomy.

Chester Stewart became highly qualified and prepared
an excellent thesis entitled Studies on the Effects of
Inanition upon Growth in the Albino Rat, and the de-
gree of Doctor of Philosophy in Anatomy was conferred
upon him in 1917. In 1918 he became instructor in
pathology at the University of Minnesota and studied
under the famous pathologists H. E. Robertson and
E.T.Bell. Throughout the years Dr. Stewart took courses
in the School of Medicine, and in 1919 he received the
degree of Doctor of Medicine. At that time Dr. J. P.
Sedgewick, Chief of the Department of Pediatrics, was
of the opinion that Dr. Stewart’s experimental work,
together with his special knowledge of anatomy and
pathology and his keen interest in the health and welfare
of children, qualified him admirably for pediatrics. Dr.
Sedgewick therefore invited him to take a fellowship.
Since he had already been in school so long, Dr. Stewart
gave this opportunity, as well as other positions that were
offered him, special consideration. He finally accepted
the fellowship, which took him to the Mayo Clinic for
part of one year. There he profited greatly by working
under the direction of the pediatrics staff. Dr. Sedge-
wick manifested a great deal of pride in Dr. Stewart’s
accomplishments. He was particularly pleased with the
doctorate thesis entitled The Vital Capacity of the Lungs
of Children in Health and Disease, and, as soon as the
Ph.D. degree in pediatrics was granted to Dr. Stewart
in 1921, recommended an appointment to an instructor-
ship in pediatrics on a part-time basis.

Dr. Stewart then opened an office for the practice of
pediatrics in Minneapolis. Like nearly all physicians who
limit themselves to specialties, in the beginning he found
time heavy on his hands. There were months when the
income from his office was so small as to be discourag-
ing, and on a few occasions he even mentioned abandon-
ing his specialty for general practice in a rural com-
munity. Throughout this slack period he busied himself
by working in clinics and public institutions, where he
gained experience but derived little financial return.
However, his fellow physicians and the few families who
had consulted him had found him so thoroughly com-
petent and trustworthy that they began referring others
to him When Dr. Frederick Schlutz discontinued prac-
tice, Dr. Stewart took over his office. This practice
brought him in contact with many new families.

Dr. Stewart retained Miss Elizabeth Noel as office
nurse and secretary. She continued in this position with
Dr. Stewart until he left Minneapolis in 1941. He
always recognized her fine qualities and thoroughly ap-
preciated her loyalty, trustworthiness, and efficiency. Sbe
played a large role in the development of his practice.

Recently she said: "I always had the greatest confidence
in and respect for Dr. Stewart, both as a physician and
a friend. His sympathetic understanding and calm good
judgment endeared him to a great many people. On
numerous occasions mothers told me how much his
thoughtfulness meant to them. One of his finest attrib-
utes was his attitude toward the poor. He was always
most sympathetic toward them, and frequently went out
of his way to help them.”

During the years he practiced in Minneapolis ( 1922 to
1941), Dr. Stewart developed as fine a clientele as any
pediatrist ever enjoyed in this city. He treated alike the
children of the poor and the rich, the illiterate and the
educated, and all intermediate groups. To him every
ill child was worthy of the best medical care that he
could provide. In the home and in the office he outlined
in detail the course he expected each mother to carry
out for her ill child, and woe to that mother who was
careless or who for any reason failed to execute his
orders. On all occasions he had the courage of his con-
victions. He never indulged in back-patting or flattery
in order to gain or retain patients.

For many years Dr. Stewart and Dr. Erling Platou
were in private practice together. Dr. Platou says:

"Close association for seventeen years with Chester
Stewart revealed to me the qualities so much to be de-
sired in a fine physician and teacher. Intellectual hon-
esty, steadfastness, scrupulousness for detail, tolerance,
and a sense of humor were some of his attributes.

"Many of us knew Dr. Stewart first as an instructor
in histology and neuro-anatomy. After completing his
doctorate in anatomy and later in pediatrics he entered
practice in Minneapolis in 1923, and in the following
year we became associated in practice.

"Despite his success as a practitioner and his leader-
ship in medical councils, he persevered in his basic love
for academic life. Early morning study, regular attend-
ance at his out-patient teaching clinic at the university;
even the tabulation of data between patient visits in
office practice attested to his keen interest in basic work.
His fine contributions to our knowledge of childhood
tuberculosis were perhaps the outstanding result of such
application.

"As full-time professor and head of the Department
of Pediatrics at Louisiana State University Medical
School he made an enviable record in the type of posi-
tion he desired and so richly deserved.”

In the hospitals Dr. Stewart was a favorite among the
conscientious nurses on the pediatrics services because
of his strict professional attitude, his vast store of infor-
mation, the uncanniness he often displayed in diagnosis,
and his fine success in treatment.

Those who knew Dr. Stewart best recognized in him
a depth of kindness and sympathy which unquestionably
contributed largely to his greatness. He so deeply sym-
pathized with the parents of severely sick children and
with the little patients themselves that his very expression
portrayed to his closest friends the pain he experienced
whenever one of them was seriously ill.

He was not a person to make a display of his good-
ness. Therefore few persons know that he frequented

134

The Journal Lancet

toy shops and fruit and candy stores for gifts that might
contribute to the happiness of little patients suffering
from prolonged, chronic illnesses or fatal conditions. He
delivered these gifts personally, and often spent long
periods teaching children how to use new toys and to
play new games.

He was particularly attracted to children with long,
chronic illnesses and those crippled for life on the pediat-
rics service of the University Hospital — so much so that
he devoted a great deal of time to the development of
plans for their entertainment and education. He was
instrumental in procuring the aid of Miss Dorothy
Jones, who had so much to offer these children. She
herself was severely handicapped physically by polio-
myelitis, but through it all had manifested such a beauti-
ful spirit in her desire to help others that she developed
faculties which overshadowed her physical handicap. She
possessed a personality that made her most attractive
and had accumulated much information that she could
transmit to others. Dr. Stewart thought that, with these
fine qualifications, Dorothy Jones was the ideal person
to be employed on a full-time basis to inspire, teach, and
help rehabilitate crippled children. As recreation leader
in the Department of Pediatrics she has become one of
the most popular and useful persons in this field. Con-
cerning him she recently said: "For ten years I was priv-
ileged to know Dr. Stewart in connection with his work
when he was in charge of the Pediatric Out-Patient
Clinic. I shall always remember his generous nature, his
unusual sense of humor in all situations, and his consid-
eration for everyone. I appreciated his genuine interest
in matters with which I had to deal involving recrea-
tional activities for children. He will be greatly missed
by the countless numbers for whom he has done many
favors in his gracious manner.”

He had a natural, keen sense of humor, which was
probably enhanced by Mark Twain. They had spent
their boyhood days at slightly different times in the vicin-
ity of Hannibal, Missouri. Mark Twain died when
Chester was twenty years old. The famous humorist had
doubtless left a marked impression on the youth of Han-
nibal. As the years passed, Dr. Stewart acquired every
available writing of Mark Twain. He read and reread
them and believed they had done much to bolster the
morale of the American public.

He never enjoyed or indulged in humor at the expense
of others, but he had a long list of wholesome jokes on
himself. A choice one began with a telephone conversa-
tion late at night when a Minnesota blizzard was raging.
An emotional mother was insistent that he make a house
call. After careful inquiry concerning the child’s symp-
toms, he was convinced that the condition was not seri-
ous, and he recommended some simple procedures and
offered to call in the morning. The mother maintained
the child was far too ill for this course and must be seen
by a physician at once. Fearing that he might have mis-
interpreted the symptoms, he decided to make the call.
Since it was his first contact with the family, he inquired
as to the address, which was approximately ten miles
from his home. He could not hope to make the round
trip in less than two or three hours. On his arrival the

child’s condition did not seem serious. He arranged for
the necessary care and told the mother he would return
during the day and complete the details of the examina-
tion. The mother replied that this would not be neces-
sary, because their regular pediatrist would not venture
out in the storm at night but promised to call in the
morning.

As a teacher, Dr. Stewart was unexcelled. Beginning
in 1914, he taught continuously in the Medical School
of the University of Minnesota until 1941. After enter-
ing the practice of medicine he never allowed the work
of his private office to interfere with his university duties.
In 1941 the University of Louisiana made him an ex-
tremely attractive offer as Head of the Department of
Pediatrics. In addition to directing the activities of stu-
dents, interns, residents, and regular staff members, there
was the opportunity of teaching any or as many of the
courses in pediatrics as he might desire. Moreover, there
was time for research and writing. For weeks he pon-
dered over this offer, sought the advice of his most in-
timate friends, and finally accepted the Louisiana post.

Throughout his years of teaching, first in anatomy,
then in pathology, and finally in pediatrics, medical stu-
dents loved him because of his sincerity and great devo-
tion to them. They respected him because of his ability
and the large fund of knowledge which he so willingly
and effectively imparted to them. His clinics were fre-
quented by students and by guest physicians from every-
where, and whenever possible nurses and social workers
attended. They were fascinated by his practical psy-
chology, which usually won the co-operation of the par-
ents. Miss lone Corliss, for many years Supervisor of
Nurses in the Out-Patient Department of the Univer-
sity of Minnesota, recently said: "Dr. Stewart and his
work in the Pediatric Out-Patient Department will long
be remembered by those who were fortunate enough to
have been associated with him. His clinics were charac-
terized by outstanding organization, unique teaching,
and intense interest in every problem confronting the
child — his social and spiritual guidance as well as mental
and physical well-being. His clinic room was crowded
with staff, medical students, and student nurses eager
to attend and profit by his unusual psychology in dealing
with children and parents.”

When Dr. Irvine McQuarrie became Chief of the
Department of Pediatrics of the University of Minne-
sota in 1930, he promptly recognized Dr. Stewart’s abil-
ity, loyalty, and fine co-operative spirit, and gave his
utmost support to all Dr. Stewart’s activities. Concern-
ing him, Dr. McQuarrie says: "In the untimely passing
of Dr. Chester Stewart the medical profession lost one
of its most valuable and most loyal members. As prac-
titioner, teacher, and clinical investigator he ranked high
among American pediatricians. His genuine and abiding
interest in the problem of tuberculosis in childhood, in
particular, and his original contributions to our knowl-
edge on that subject gained for him an enviable repu-
tation, both in this country and abroad. His pre-eminence
in the field was evidenced by his being invited to write
the original chapter on tuberculosis in children for Bren-
nemann’s Practice of Pediatrics and by his being selected

May, 1946

135

to present some of his original contributions before the
International Pediatrics Congress at Rome, Italy, in the
year 1937.

"That his interests were not confined to studies in the
clinic and laboratory is well known to all his numerous
friends. They will always remember him for his zeal and
sincerity in working for improved health conditions in
his community through co-operation between practicing
physicians and public agencies, both in Minnesota and
Louisiana. While he approached every progressive cause
in the spirit of a crusader, his sense of humor and a
profound respect for the practical kept his course of
action on an even keel.

"His departure has left a void in the medical faculty
of the University of Louisiana which is almost paralyz-
ing to that institution. All his Minnesota colleagues who
were fortunate enough to know him intimately will like-
wise long continue to miss his stimulating influence and
his reassuring smile. Our only consolation is that his
friendship and his good works will always remain grati-
fying memories to enrich our daily lives.”

Dr. Stewart was always loyal to the Medical School
of the University of Minnesota and greatly respected the
three deans under whom he worked, Lyon, Scammon,
and Diehl. They, in turn, held him in high regard.
Dean Diehl says: "I knew Chester Stewart over a long
period of years, and have spent many pleasant moments
reviewing our early associations. I remember him first
as a most able instructor in anatomy, in which field he
did his doctorate before entering Medical School. I am
sure the medical students in the anatomy laboratory at
that time agree that Dr. Stewart could have become an
outstanding anatomist should he have chosen such a
career instead of pediatrics. His next, equally success-
ful, service was as instructor in pathology, where he re-
mained for three years until his appointment in pediatrics
in 1919. I shall not repeat his contributions in the final
field of his choice; they are familiar to all his colleagues.
I should like rather to emphasize his unique abilities as
a scholar, scientist, and teacher in three important spe-
cialties of medicine. In all three he won the respect,
esteem, and affection of students and colleagues. He
was truly a scholar of wide academic interests, and a
grand gentleman.”

At the University of Louisiana Dr. Stewart also be-
came a favorite among students and faculty members.
He instituted new projects which were readily accepted
for the benefit of the University and all concerned.
Upon the announcement of his death the Medical
School was closed for the day, and the faculty and stu-
dent body came to pay tribute to him and to mourn the
loss of a great teacher, co-worker, and friend. Miss
Jurisich, his secretary, and Miss Boudreaux, department
technician, said: "Although there are many who are able
to pay fitting tribute to Dr. Chester A. Stewart with
reference to his outstanding work in the field of pediat-
rics, we, his secretary and technician, would like to ex-
press our esteem for him as a man, an employer, and a
friend. Through a close association we came to know
Dr. Stewart as a man who possessed high personal and
professional ideals, a man who at all times was ready

to serve any who called upon him for assistance, a man
whose character and personality were founded on his
innate qualities of loyalty and honesty. The medical
world has been deprived of a truly great physician, but
our loss was personal in that we lost a staunch and
valued friend.”

As a medical lecturer, Dr. Stewart was in great de-
mand. He was frequently invited to participate in the
programs of county, state, and national medical organi-
zations. His material was always well organized, and
his presentations were concise and appropriately illus-
trated.

As a medical writer, Dr. Stewart excelled. He pos-
sessed an abundance of native ability and was especially
trained in this art by his first chief, Clarence M. Jackson.
No one could have a better teacher. On one occasion he
took special work in mathematics with particular refer-
ence to statistical analysis, in order that he might treat
data statistically in his various publications. His first
article was published in the Biological Bulletin in 1916,
under the title "Growth of the Body and of the Various
Organs of Young Albino Rats after Inanition for Vari-
ous Periods.” His last article appeared in the New Or-
leans Medical and Surgical journal of January 1946,
under the title "A Tuberculosis Survey of New Or-
leans.” At the time of his death he was working on a
chapter on tuberculosis for a book on infectious diseases,
to be published by Dr. Roscoe Pullen. Altogether, Dr.
Stewart published more than a hundred articles in jour-
nals, in addition to several chapters in books. He had
been solicited by various publishers regarding the prepa-
ration of a book on the care and feeding of infants,
a field in which he was exceedingly expert and to which
he had contributed some innovations. He fully intended
to write this book as soon as some of his more pressing
work was finished. When the Journal Lancet staff
was reorganized in 1930 he was selected to represent
pediatrics. He proved to be a most valuable member
until his death, and for many years edited the special
pediatrics number published each May.

Dr. Stewart wrote on numerous subjects, such as in-
anition, vital lung capacity, infant feeding, and various
diseases of infants and children. Aside from infant feed-
ing, the subject that lay closest to his heart was tuber-
culosis. In fact, approximately half his publications were
on this disease. His interest in the subject was especially
stimulated in 1921, when, with the organization of the
medical staff of the Lymanhurst School for Tuberculous
Children, he became the chief pediatrist. Of the various
diseases, he recognized tuberculosis as the principal en-
emy of mankind, and he was firmly convinced that its
control is dependent upon the protection of children
against the primary attack and teaching them to avoid
tubercle bacilli throughout life. At Lymanhurst he
seized the splendid opportunity for examining, treating,
preventing, and making follow-up observations on large
numbers of children. His observations on tuberculosis
led to conclusions that completely revolutionized some
previous concepts on this subject. He regarded tuber-
culosis as an extremely contagious disease and taught
that exposure to open cases is dangerous to children and

136

The Journal Lancet

adults alike, and that it is hazardous to persons who
have previously been infected, as well as to those who
never before have taken the bacilli into their bodies.
Therefore, he was a strong supporter of the adoption
of rigid contagious disease technique in hospitals and
sanatoriums in order to protect students of nursing and
medicine against first infection and reinfection. He was
the first to study carefully the tuberculous infection
attack rate among both children and adults, and found
that in the area where he worked, the rate was only
about one per cent per year.

While chief of the medical staff of the Swedish Hos-
pital in Minneapolis in 1932, he convinced the adminis-
tration and the professional members that the entire per-
sonnel, as well as all patients admitted, should be tested
with tuberculin, that all reactors should have X-ray in-
spection of the chest, and that those who presented shad-
ows should have the etiology of their disease determined.
Several previously unsuspected cases of tuberculosis were
found, two of whom were from the full-time personnel
of the institution. Dr. Stewart then encouraged periodic
tuberculin testing of all student nurses, with the neces-
sary subsequent phases of the examination. This pro-
cedure proved so valuable that it is now one of the
main health activities among the students, with the re-
sult that not a single case of clinical tuberculosis has
developed among them in several years.

At the University of Louisiana Dr. Stewart initiated
a program of tuberculosis control among the students
and faculty, both at Baton Rouge and New Orleans.
This program consisted of first administering the tuber-
culin test, then making X-ray inspection of the chests
of the reactors, with complete examination of those who
presented shadows that might be due to tuberculosis.
This ideal program is now in effect in that institution.

Pediatrists of the United States have been far more
alert and have had a clearer vision of tuberculosis con-
trol than any other group of physicians. Among them
Dr. Stewart was a leader. Indeed, he became almost as
well known among the chest specialists and tuberculosis
experts of this country as among the pediatrists. His
articles were read and he was quoted everywhere. At
the time of his death he was a member of the committees
on tuberculosis of the American Academy of Pediatrics
and the American School Health Association. He was
a member of the Executive Committee of the Tubercu-
losis Association of New Orleans. He was First Vice-
President and a member of the Board of Directors of
the Louisiana Tuberculosis Association and a member
of the Board of Directors of the National Tuberculosis
Association. As a committee member he actively partici-
pated in the preparation of the manuscript entitled
"Diagnostic Standards,” published by the National Tu-
berculosis Association in 1940.

In medical organization Dr. Stewart was a master.
He believed that all health activities should be directed
by medical societies, which, in turn, should co-operate
with allied groups, such as lay tuberculosis associations
and official health departments. As a member of the
Hennepin County Medical Society he did such effective
work on various committes that he was elected to the

presidency in 1933-34. Under his leadership the So-
ciety had one of the most successful years in its his-
tory. On the recommendation of his county society he
was elected to membership on the Council of the Min-
nesota State Medical Association in 1938, and held this
position during the remainder of his stay in Minnesota.
He was an extremely valuable member, introducing one
innovation after another. Through his efforts the Com-
mittee on Tuberculosis of the State Medical Association
was revived. He found time to meet with this committee
regularly and some of its most outstanding activities,
such as the Meeker County Project, were strongly sup-
ported by him. He expressed the opinion that the plan
for accrediting counties on the basis of achievement in
tuberculosis control might well be the beginning of a
great nation-wide movement. In New Orleans he par-
ticipated actively in local and state medical organizations.

While a student at the University of Missouri, Ches-
ter joined the Phi Beta Pi fraternity, and he remained
a loyal member throughout his life. He took great pride
in the C. M. Jackson lectureship established by the Min-
nesota chapter. How fitting it would be for the Phi
Beta Pi chapters at Missouri, Minnesota, and Louisiana
to create fellowships or lectureships to perpetuate the
name and the accomplishments of another famous mem-
ber, Chester Stewart.

From the time his brothers were small children, Ches-
ter took great interest in their welfare. He encouraged
and supported them in every possible way. He lived to
see both of them achieve success — Rollo as a splendid
surgeon, and Benjamin as an outstanding florist, now
president of the Minneapolis Florists’ Association. Dr.
Stewart’s fine character was again displayed in the con-
sideration he manifested for his mother. Until she died
at the age of seventy-five years he did everything possible
to insure her comfort and happiness. His sympathetic
understanding and kindness in the declining years of her
life were a joy to behold.

Throughout the years Mrs. Stewart maintained a keen
interest in all Dr. Stewart’s activities. She encouraged
him in every undertaking, and he relied strongly on her
judgment. Indeed, she is responsible in no small way
for his numerous achievements. They provided every-
thing possible for the welfare of their three children,
who were well on their way to successful lives at the
time of Dr. Stewart’s departure — John had graduated
from college and is established in business, William had
graduated from medical school, and James was a student
in veterinary medicine. In their mother and father they
have a grand heritage.

For approximately one third of a century Dr. Stewart
and I were most intimate friends. Probably no other
physician knew him and understood him better than I.
Together we camped, fished, took long trips, joined lay
and scientific organizations, served on committees, taught
the same courses, occupied the same office, prepared and
published articles and chapters for medical journals and
books, served on the same hospital staffs, argued and
discussed our mutual problems and interests, and attend-
ed numerous medical meetings in various parts of the
country. For twenty years we lunched together nearly

May, 1946

137

every working day, saw one another’s patients in con-
sultation; indeed, we did everything that close friends
do together. On these precious experiences and remem-
brances I could write a large volume about Chester Stew-
art, every word of which would be in his favor. In his
whole life I knew of nothing bad. If he made mistakes
or did harm to anyone, it was never intentional. His
life was one of constant constructive endeavor.

In a letter of February 2, 1946, Dr. Stewart invited
me to be guest speaker at the annual meeting of the
Louisiana State Tuberculosis Association, to be held
early in May. The last sentence of his letter read,
"I think your visit here will do my angina some good.”
This was the first time he had intimated to me that
he was suffering from this condition, although we had

been together on several occasions one month earlier.
My letter of acceptance was mailed on February 7, but
the following morning at 4 o’clock he developed a
severe attack and died from coronary occlusion six hours
later. His death was untimely at fifty-six years. Retire-
ment from Medical School activities would not have
come for a dozen more years. Although his death was
premature, he contributed more for the good of human-
ity in fifty-six years than most of us are capable of
doing in a hundred. At the close of his life probably
nothing would have been more pleasing to him than
the simple, all-inclusive, and now frequently heard ex-
pression, "Well done!” The knowledge he gave the
world can never die. Through the minds and hearts of
others Chester Stewart will continue to live.

B&oU llwUws

Gastro-Enterology. Volume III: The Liver, Biliary Tract
and Pancreas, and Secondary Gastro-Intestinal Dis-
orders. By Henry L. Bockus, M.D. Philadelphia and
London: W. B. Saunders Company, 1946. Pp. 1091, with
427 illustrations, some in color. Three volumes with separate
desk index, $35.00.

With the publication of the third volume of Bockus’s Gastro-
Enterology , a work that for many years will remain the defini-
tive description and exposition of gastro-entero-colic and hepato-
biliary diseases has been completed. This volume, to a greater
extent than the other two, includes sections written by the
author’s colleagues of the Graduate School of Medicine of the
University of Pennsylvania, but the Osler-Christian tradition is
retained. That is, the conclusions and opinions are irradiated
and mellowed by the experience and wisdom of the author and
editor. For a universal treatise, such a presentation of the sub-
ject is valuable for the student and for practitioners with lim-
ited opportunities for observation of gastro-enterological dis-
eases. But the text, with the references, is also sufficiently com-
plete to satisfy the demands and augment the knowledge of the
specialist.

The approach to all problems of diagnosis and therapy is
sane and practical; the author has no foibles and advocates
no fads.

The section concerned with the pancreas is informative and
also provocative of further studies of pancreatic function and
consequent improved acuity in the diagnosis of diseases of this
enigmatic organ.

Manifestations in the gastro-enterologic system of diseases
primary elsewhere and purely functional derangements are dis-
cussed adequately, albeit too briefly, in Section 11. Complete
elucidation of such disturbances, which comprise about half
of those confronting the gastro-enterologist, would require
another volume. — J. B. C.

Rehabilitation at Lake Tomahawk State Camp, by Harold
Holand, Director, Research Department, Wisconsin Anti-
Tuberculosis Association. National Tuberculosis Association,
1790 Broadway, New York, New York, 1945.

The rehabilitation of the tuberculous patient is an extremely
important part of the tuberculosis control program. One of the
early ventures in this field was at Lake Tomahawk State Camp
in Wisconsin. In this book the author presents in a fascinating
manner the history of development, the techniques employed,
and the accomplishments of the camp.

A private sanatorium, River Pines, was opened at Stevens
Point, Wisconsin, in 1906. During the next year the state
sanatorium began to admit patients, and by the fall of 1912
Wisconsin had two private and four public sanatoriums, with
a total bed capacity of approximately 300.

After the Wisconsin Anti-Tuberculosis Association came into
being, it was observed that many of the patients discharged
from the sanatoriums soon had reactivation of their disease.
The idea was conceived of establishing a place where discharged
sanatorium patients could be kept under close supervision while
their working capacities were gradually restored. At first it was
thought that patients who had been adequately treated in sana-
toriums should be transferred to Lake Tomahawk State Camp,
where they could devote their working time to restocking the
forest. Thus the camp was established in 1915 for the dual
purpose of rehabilitating patients and building up the forests.
However, it was ruled that the state lacked constitutional
authority to carry on a forest reserve program, and therefore
other work had to be considered for the patients. At first it
was a matter of trial and error, but a satisfactory rehabilitation
program was slowly evolved, so that the Lake Tomahawk State
Camp has become favorably known among tuberculosis workers
throughout the world.

The author points out that during the twenty-four years of
the existence of this camp up to 1939, 755 persons were treated
and discharged alive. After carefully analyzing the data he
says that the post -discharge statistics give considerable docu-
mentary testimony to the value of this rehabilitation program.
The step now being developed consists of providing a more defi-
nite procedure for placement of graduates of this camp in
suitable employment. The author gives much well-deserved
credit to Mr. and Mrs. Frank A. Reich, builders and trustees
of the camp since its opening.

Mr. Holand is to be congratulated on the preparation of this
book because of its historical value, the fine manner in which
he has discussed the pros and cons of rehabilitation, and the
future program he proposes. — J.A.M.

Clinical Electrocardiography, by David Scherf, M.D., and
Linn J. Boyd, M.D. 2d edition; Philadelphia: J. B. Lip-
pincott Company, 1946. Pp. 268, illustrated, $8.00.

The senior author of this book was a co-worker of Wencke-
bach in Vienna. In recent years he has been Associate Pro-
fessor of Medicine at New York Medical College. This work
reflects his excellent training in both the English and German
cardiologic literature. The book is clinical to the extent that a
great number of pathological conditions of significance to the
electrocardiographer are considered, but the authors also dis-
cuss the physiological and experimental bases of many of their
conclusions. The book compares favorably with other standard
works on electrocardiography. It presents an epitome, well illus-
trated, of present knowledge of the subject. — R.B.

138

The Journal Lancet

The Challenge of Postwar Pediatrics

A. A. Weech, M.D.

Cincinnati, Ohio

Suffering, starvation, and despair for many people
have been and for some time must continue to be
the outcome of World War II. Such cataclysms have
always been followed by change, sometimes retrogressive,
sometimes forward moving, in its effect on civilization.
The challenge to those who survived the debacle of this
war is plain. By planning now can they block completely
the type of change that spells regression, and from the
lessons of war gather the momentum for progress? The
best brains of the civilized world must consider carefully
the means of making the answer "Yes.” There are
ramifications in economics, social security, education,
sanitation, public health, and a score of other fields.
Statesmen must draw the master plan, but the details
belong to professional and intellectual groups in every
walk of life. For this reason and from this point of view
I have chosen to write on "the challenge of postwar
pediatrics.”

The broad outline of the challenge is clear. It em-
braces a wider horizon than routine calls to the homes
of the sick. Shall the profession be so organized and
so constituted that its members will continue and seek
to expand their work in the field of preventive medi-
cine? Through national, state, and municipal organiza-
tions can they be kept informed of relevant scientific
discoveries and brought to comprehend their significance
from the standpoint of application to the child? Is it
too much to hope that, having comprehended, the pro-
fession will overcome inertia, not only in accepting an
obligation for detailed work but also in creating within
itself the means of leadership, so that co-ordinated opin-
ions and experience can be utilized when the enterprise
requires co-operation with industry, education, govern-
ment, and other agencies outside the medical profession?

Some startling situations were revealed by physical
examinations of the young men of the nation under the
Selective Service Act. From the assembled data we can
specify the points where preventive medicine has failed.
We can do more. In the data themselves there is tan-
gible evidence that many disqualifying physical defects
had their origin in the years of childhood. Black' has
plotted the percentage of selectees qualified for military
service against the age of the selectees (Figure 1).* * The
available points cover the range from 18 to 36 years and
lie along a straight line. At 18 years 83 per cent were
qualified, as opposed to only 30 per cent at 36 years.
If the line is extrapolated to the younger period we must
move to 12 years before reaching the age where essen-
tially no boys have defects so marked as to disqualify
for military service. Although there are legitimate ob-

From the Children’s Hospital and the Department of Pediat-
rics, University of Cincinnati College of Medicine.

*For the data that appear in Figure 1 I am indebted to an
article by Lt. Comdr. Arthur Black of the United States Navy
(see Bibliography).

Fig. 1. Showing the percentage of selectees qualified for
general military service at different ages in 1941. (After
Black.)

jections to projecting this line to the 100 per cent quali-
fied level, there is certainly no evidence to suggest uni-
versal qualification at any older age than 12 years. Re-
member, we are speaking of advanced defects sufficient
to disqualify for a soldier’s life. The seeds from which
the defects grew must have been planted at even earlier
ages. One phase of the postwar challenge is clearly en-
meshed with the pediatric age.

Let us turn to the actual causes for rejection and the
accumulated totals. Of 2,000,000 men examined in
1941, 900,000 were rejected for physical and mental
disabilities.- Forty-five per cent of the young manhood
of the nation with major defects! Although standards
were subsequently altered so that some of those rejected
found a place for service, it is no credit to the science
of preventive medicine that the demand for manpower
should have necessitated changing the standards.

At the top of the causes of rejection is dental caries.
Of the total, 188,000, or between 9 and 10 per cent
of the young men, failed to meet the dental require-
ments. Perhaps you may think that the standard was
too high. It hardly seems so. For Class 1A a selectee
must have "a minimum of three serviceable natural mas-
ticating teeth above and three below opposing and three
serviceable natural incisors above and three below op-
posing. (Therefore, the minimum requirements consist
of a total of six masticating teeth and six incisor teeth.)
All of these teeth must be so opposed as to serve the
purpose of incision and mastication. The term masticat-
ing teeth includes molar and bicuspid teeth, and the term
incisors includes incisor and cuspid teeth.” These stipu-
lations are quoted from the United States War Depart-
ment Mobilization Regulations MR 1-9, issued August
31, 1940. The large number of men unable to meet the

May, 1946

139

requirement is the more startling in view of the gen-
erosity of these regulations.

Dental caries is certainly not exclusively a pediatric
problem, but just as certainly the pediatrician is not
justified in unloading all the responsibility for correction
and prevention on the dentist. At present the only
established way of controlling the spread of caries con-
sists of periodic visits to the dentist, beginning at the
age of two or three years and continuing throughout
life. Many families are unable to meet the cost of reg-
ular dental supervision. For them there is need of sub-
sidized care. But they probably constitute a smaller
group of people than those who are able to bear the
costs but fail to make the regular visits through procras-
tination and possibly through fear of the dentist’s drill.
With this latter group the pediatrician can help by pa-
tient persuasion and constant insistence that parents do
not neglect one phase of a child’s health while seeking
advice about another.

We are not yet strong enough in our knowledge of
other means of preventing caries to permit the parent
to believe that periodic trips to the dentist can be
avoided. There are nevertheless clear signs that the
spread of caries can be influenced by systemic factors.
Since the control of these factors enters the domain of
pediatric practice, serious consideration is needed of ways
of making the control effective.

There is no longer room to doubt that the tendency
of teeth to decay is affected by nutritional factors. Au-
thorities are not agreed, however, on the relative pro-
phylactic importance of the different dietary essentials.
Although research in this direction needs to be contin-
ued, the need for more work does not remove the re-
sponsibility of giving the child the chance to benefit
from all that is now known of the completely balanced
diet. The observations of Boyd 3 in Iowa argue strongly
that such diets can arrest the progress of caries. Chil-
dren subject to rigid control of diet because of diabetes
exhibited a greatly lowered caries rate in comparison
with children whose diets were not so carefully super-
vised.

The application of this knowledge in daily practice
is not easy. The eating habits of the seemingly healthy
child cannot be regarded as something requiring rigid
military discipline. Parental strain and childhood rebel-
lion against such a course would soon lead to emotional
disturbances in the home too great to justify a discipline
that is accepted willingly when a disease like diabetes
furnishes the motive.

Fortunately, another way is open, a way too seldom
used. I refer to the dietetic analysis of carefully pre-
pared records of what the normal and wisely disciplined
child is choosing to eat at home, at school, and at the
corner soda fountain. Data are now available that make
it possible to appraise the analysis from the standpoint
of most of the known food essentials. The appraisal
becomes the basis for advising substitutes and alterations
that allow the child a maximum of freedom with respect
to his own choice of food. It is frankly admitted that
the time required for calculating the components of
freely-chosen diets may prevent the busy practitioner

from using this method routinely. The difficulties con-
stitute the challenge. And perhaps the expanding num-
ber of well-trained dietitians can help us meet the
challenge.

I have purposely mentioned nutrition first among the
systemic factors affecting the incidence of caries because
a wisely selected diet has more to commend it from the
health standpoint than merely the prevention of caries.
The time may be near, however, when substantial prog-
ress in the fight against tooth decay will be accomplished
by the relatively simple procedure of adding fluorides
to municipal water supplies. By means of studies in
carefully selected communities Dean and his associates 4
have demonstrated a remarkable inverse relationship be-
tween caries experience and the level of fluorine in the
water supply. The relationship holds throughout ranges
of concentration that are too low to produce mottling
of the enamel or other toxic manifestations. The effect
of fluorine in inhibiting the development of caries in
rats maintained on a caries-producing diet suggests
strongly that the relationship observed in human beings
is neither fortuitous nor the result of some associated
unknown factor.

It is imperative that we be familiar with the evidence
rapidly accumulating in this field. Individually we must
weigh the evidence thoughtfully, in order that, collec-
tively, we shall be ready to assume the role of leader-
ship when we are convinced that the time for action is
at hand. Personally, I am persuaded that enough data
have already accumulated to justify several carefully
conducted surveys of the effect of adding nontoxic
amounts of sodium fluoride to city water. Plans for
such surveys have already been prepared by Ast of the
New York State Department of Health and published
in the United States Public Health Reports.

I have wondered whether as individual pediatricians
we should not do more than this. The amount of flu-
orine in the water of most American municipalities is
far below the level that inhibits caries. Water from
Cincinnati, Pittsburgh, and Chicago is reported as show-
ing a trace. Water from New York City contains one
part in a hundred million. Water from Cleveland, In-
dianapolis, and Detroit shows one part in ten million.
Available evidence indicates that the amount needed to
exert a substantial effect on tooth decay is in the neigh-
borhood of one part per million.

The question at once arises, "Can the risk of caries
be reduced by adding daily equivalent amounts of so-
dium fluoride to the orange juice or milk of individual
children during the span of years when the crowns of
the permanent teeth are being laid down?” Although
the time may not have arrived when a supplement of
this kind can be recommended as a desirable universal
measure, there is nevertheless ample evidence to justify
suitably controlled experimental observations on limited
groups of children. For the caries-fluorine hypothesis
already has more to commend it than has been assembled
in behalf of the time-honored toothbrush.

Enough, then, of dental caries and the challenge it
presents to postwar pediatrics. The experience of Selec-
tive Service indicates that 4.8 per cent of the young

140

The Journal Lancet

men of the country were disqualified by cardiovascular
diseases. The group includes defects from several etio-
logic agents, but among them rheumatic disease is by
far the most important. Rheumatic fever is now killing
more children of school age, i.e., 5 to 14 years, in the
United States than any other disease.0 You are all
familiar with the story. The disease is characterized by
a tendency to recurrences over many years. Each attack
means months of bed care. The case fatality before
maturity is certainly not less than 20 per cent. Here
indeed is a challenge to pediatricians ready to occupy
their thoughts with the problems of preventive medicine.

It is true that we know of no sure way to prevent
a first attack of rheumatic fever. However, the deaths
from rheumatic disease are for the most part the result
of recurrences, and here there is the opportunity for
prophylaxis. Observations by Coburn and Moore 1 and
by Thomas and France 8 have recently been corroborated
in meticulous studies by Kuttner and Reyersbach 9 at
Irvington House in New York. These studies show not
only that recurrences of rheumatic activity are invariably
ushered in by infections with group A hemolytic strep-
tococci, but also that the incidence of streptococcal in-
fection can be greatly lowered by giving small daily
doses of sulfanilamide throughout the season of the year
when respiratory infections are prevalent.

The data collected by Kuttner will serve to illustrate
the effectiveness of this form of prophylaxis. Among
108 rheumatic children who received daily doses of sul-
fanilamide through two successive winters there were
only two streptococcal infections, and only one of these
was associated with a recrudescence of rheumatic activity.
In contrast, among 104 rheumatic children in the con-
trol group there were 48 streptococcal infections, asso-
ciated with 23 recurrences of rheumatic activity. Statis-
tically this result is overwhelmingly significant. Prophy-
lactic sulfanilamide does exhibit an important action in
preventing recurrences of acute rheumatic disease. But
we must note that Kuttner found that 15 per cent of
her rheumatic subjects could not be kept on the drug
because of toxic reactions. The challenge to those who
will use this method therefore involves the responsibility
for alertness in looking for signs of toxic response. The
responsibility will not be eliminated even if the number
of untoward reactions is reduced when newer drugs, like
sulfadiazine and sulfamerazine, are substituted for sul-
fanilamide.

I have stated that we know of no sure way to prevent
a first attack of rheumatic fever. But we do know that
the malady is far more frequent in the underprivileged
classes than among the well-to-do. We do not yet know
the full explanation. Perhaps the major factor is over-
crowding, with consequent enhanced liability to strepto-
coccal infection. Perhaps other and more easily cor-
rectable factors are at work. At all events, Coburn and
Moore 10 have recently published the results of an in-
vestigation which arrests attention by suggesting that
nutrition may be an important factor in determining
susceptibility to rheumatic disease. In one phase of this
work Coburn was led to collect and analyze the dietary
records of 50 rheumatic children. Of these children,

Table 1

Diet and Recurrent Activity in Rheumatic Subjects
(Data of A. F. Coburn and L. V. Moore)

Vitamin A

Less

and Protein

Susceptible

in Diet

Subjects

Total

Above median in

both

items

Below median in

both

items

Total

Chi-square (after Yates’s correction) — 12.5. P n 0.0005.

25 had suffered at least one severe attack of rheumatism
with cardiac involvement early in life, but they had been
free from attacks for many years, and the other 25 had
experienced repeated attacks over the intervening years.
All the patients were under regular observation in the
out-patient clinic, and all were free from active disease
at the time the dietary records were obtained. The rec-
ords were subsequently analyzed to determine what the
diets provided in calories and protein, in calcium, phos-
phorus, and iron, and in vitamins A, B, C, D, and G.
Significant associations were found between susceptibility
to recurrent attacks and a number of the dietary essen-
tials.

Diets low in one essential were so frequently low in
several essentials as to preclude evaluation of the rela-
tive importance of single factors. The data in Table 1,
which show the association between susceptibility and
combined dietary deficits in protein and vitamin A, are
illustrative only, and not intended to convey the impres-
sion that these factors are either more or less important
than other factors. Estimates of the dietary level of each
constituent on the basis of published standards are not
used in this part of Coburn’s analysis. Rather, the dif-
ferent amounts actually ingested by the 50 children were
divided at the median amount, so that half the children
taking a smaller amount of the constituent could be
separated from the other half who took a larger amount.
On this basis there were 32 children who were above or
below the median levels with respect to both protein and
vitamin A. The table shows that among 16 rheumatic
children with relatively high intake of these essentials
only three exhibited recurrent activity. In contrast,
among the 16 rheumatic children with relatively low in-
takes 14 had experienced repeated attacks.

These observations are important, not only because
they point the way to another avenue of attack against
the scourge of rheumatic fever, but also because they
provide one more example of good to be derived from
an intelligently planned diet.

The Selective Service tabulation reveals that nearly
3 per cent of the nation’s registrants were rejected for
nervous and mental disorders. The diagnoses include
various types of behavior disturbances, alcoholism and
drug addiction, stuttering, stammering, habit spasms,
and enuresis. Many of these disorders might have been
prevented if the victims had had access at an early age
to wise psychiatric guidance. Here indeed is the field
that presents the supreme challenge to postwar pediat-
rics. The problems reach deeply into the causes of un-

May, 1946

141

happy homes and emotionally unstable or often merely
bewildered parents and children. The minor disturb-
ances are vastly more numerous, and, in terms of total
effect in disturbing the happiness of homes, more im-
portant than the relatively few disorders that were severe
enough and had persisted long enough to disqualify for
Selective Service.

The problem is so large and the need so great that
there is ample room for help from many points of con-
tact between society and the home — from the kinder-
garten and school, from child guidance clinics, from
social workers and visiting nurses, as well as from the
pediatrician and consulting psychiatrist. Throughout
these groups there is the need for mutual understanding.
The pediatrician especially is faced squarely with the
obligation of initiative in seeking the means of co-
operative effort. For he cannot honorably continue as
the counselor of distressed families while remaining in
ignorance of objectives and technics emanating from
psychiatry, whether or not he ultimately disagrees with
some points of view and some methods of approach.

The path along which we can approach the goal is
already becoming clear. Able young physicians who have
received a thorough training in pediatrics must be en-
couraged to study psychiatry under the best psychiatric
teachers. They must familiarize themselves with the or-
ganization of the best child guidance clinics and the
methods used in operating them. They must then — at
least for some years to come — be willing to return as
teachers to the children’s hospitals and university depart-
ments where pediatricians are being trained and where
clinical conferences are held for the benefit of physicians
practising in the community. In this way the pediatric
psychiatrist will become the important means of creating
the psychiatrically-minded pediatrician equipped with
trained insight into the significance of the emotional
environment of his patients. The wisdom of this method
of approach to the problems of pediatric psychiatry has
already been demonstrated. The Commonwealth Foun-
dation in New York City has accepted a share of the
challenge by providing a number of scholarships for the
support of pediatricians interested in obtaining psychiat-
ric training.

These suggested means whereby one may reasonably
look ahead to better management of the emotional be-
havior disturbances of childhood are directed toward
preventing the progress of a disorder as soon as it be-
comes apparent. To a certain extent the pediatrician
charged with the care of a child from the neonatal
period is in a position to offer prophylaxis. But many
pediatricians will feel, as I do, that personal guidance
by individual physicians is not enough to cope with the
magnitude of the problem. Is it not possible that pro-
phylaxis in the form of preparation for the emotional
strains of motherhood can be begun during the high

school and college age? Must we not soon recognize in
our educational institutions that impulses arising in the
hypothalamus are just as important as those coming
from the cortex in determining the actions and charac-
ter of human beings? May we not hope that the time
is near when our adolescent children not only will be
taught the importance of suppressing uncontrolled emo-
tional outbursts but will also be given an insight into
the nature of the elemental impulses and reactions that
in varying degree are the experience of all men and
women? These are matters that deserve grave thought.
Positive action lies in a field outside the domain of
pediatrics. Nevertheless, the pediatrician is concerned
because his contact with the emotional strains within
many homes has given him firsthand knowledge of con-
ditions as they are and created a responsibility he has
no right to ignore.

Conclusion

The picture I have painted of postwar pediatrics, of
the challenge and the opportunity it presents to postwar
pediatricians, is one that not only recognizes the need
for service to individual patients but also embraces a
concept of greater good to be accomplished through
leadership and co-operation with all human agencies con-
cerned with the rearing of healthier and happier children.

The specific illustrations of opportunities that lie ahead
may not be the best that could have been selected. Cer-
tainly they constitute no more than illustrations, and
are in no sense a complete program. But they have
served to stress two points which together are the back-
bone of the thesis. First: postwar pediatrics, even more
than prewar pediatrics, must accept the challenge of
preventive medicine. Second: to do so with greatest

efficiency it must seek to work with, not to argue against,
leaders in other fields that exist to prepare the child for
the responsibilities of citizenship and to protect him
against exposures that can undermine his physical health.

Bibliography

1. Black, A. P.: Mil. Surgeon, 91, 619, 1942.

2. Rountree, Col. L. G.: New York J. Dent., 12, 100, 1942.

3. Boyd, J. D.: J. Am. Dent. Assoc., 30, 670, 1943.

4. Dean, H. T.: Pub. Health Rep., 53, 1443, 1938. —

Dean, H. T., Jay, P., Arnold, F. A., McClure, F. J., and
Elvove, E.: Pub. Health Rep., 54, 862, 1939. — Dean, H. T.,
Jay, P., Arnold, F. A., and Elvove, E.: Pub. Health Rep.,

56, 365, 761, 1941. — Arnold, F. A., Dean, H. T., and
Elvove, E.: Pub. Health Rep., 57, 773, 1942.

5. Ast, D. B.: Pub. Health Rep., 58, 857, 1943.

6. Huse, B.: The Child, 7, 158, 1943.

7. Coburn, A. F., and Moore, L. V.: J. Clin. Investigation,
18, 147, 1939; M. Clin. North America, 24, 633, 1940;
J.A.M.A., 117, 176, 1941.

8. Thomas, C. B., and France, R.: Bull. Johns Hopkins

Hosp., 64, 67, 1939. — Thomas, C. B., France, R., and
Reichsman, F.: J.A.M.A., 116, 551, 1941.

9. Kuttner, A. G., and Reyersbach, G.: J. Clin. Investiga-
tion, 22, 77, 1943.

10. Coburn, A. F., and Moore, L. V.: Am. J. Dis. Child.,
65, 744, 1943.

142

The Journal Lancet

The Celiac Syndrome

Richard B. Tudor, M.D., and Erling S. Platou, M.D.
Minneapolis

Anyone interested in the celiac syndrome cannot but
l. be impressed by the great advances made in our
knowledge of it during the last three years. Work done
by Blackfan, May, McCreary, Andersen, Farber, and
many others has done much to clarify this problem.1-0

We have been particularly interested in the celiac syn-
drome during the last three years because of the number
of patients seen with the complaint of steatorrhea. This
report deals with 21 children on whom we were able to
do all necessary diagnostic tests, and to treat them and
follow the course of the disease. We have not included
several children whom we observed but upon whom we
were unable to complete tests. It is our desire to confine
the present discussion to the diagnostic and treatment
procedures.

Table 1 shows that of the 21 patients upon whom we
were able to perform all diagnostic tests four had fibro-
cystic disease and 17 had idiopathic celiac disease. In
one patient of the idiopathic type steatorrhea was due
to allergy and in one to starch intolerance; in the remain-
ing 15 the cause was not found. These 15 patients form
the chief basis of this presentation.

Table 1

Types of Cases of Celiac

Syndrome Treated

Type

Number of

Cases

Fibrocystic diseases

Idiopathic celiac disease

Fat intolerance

Starch intolerance

Total

Table 2

Symptomatology of the Celiac Syndrome
Types Symptoms

Fibrocystic

..Chronic upper respiratory infection (usually)
Steatorrhea (occasionally)

Allergic

Eczema, asthma

Idiopathic ....

Steatorrhea

All types ....

Failure to gain on adequate diet

Loss of muscle tone

Anemia

Irritability

Deficiency states (vitamins A and D)

In Table 2 are listed the most common symptoms in
each type. Of the four children with fibrocystic disease
two presented as a chief complaint chronic upper respira-
tory infection, beginning practically from birth. In two
of these four children steatorrhea as well as respiratory
infection was present.

From the Department of Pediatrics, University of Minne-
sota Medical School.

The child with steatorrhea due to allergy had severe
eczema almost from the time of birth, and was critically
ill on several occasions with a combination of eczema,
steatorrhea, and dehydration. She developed asthma at
the age of three years. The other 16 children had as
their chief complaint steatorrhea only, varying from mod-
erate to severe degree.

All children had the following physical signs: failure
to gain weight on an adequate diet, loss of muscle tone,
irritability, mild to moderate anemia, and vitamin A and
D deficiencies (Table 2).

Table 3

Laboratory Aids to Diagnosis of Celiac Syndrome

Test of stool fat

Vitamin A absorption curve

Fasting carotene test

Sugar tolerance curve

Pancreatic enzyme studies

History and skin tests for allergy

X-rays of chest and gastrointestinal tract

In Table 3 are listed all the laboratory aids to diag-
nosis. As most patients with the celiac syndrome have
steatorrhea it follows that their stools contain more fat
than normal. For children under the age of six years
total stool excretion of more than 50 grams wet weight
or 15 grams dried weight is beyond the limits of normal.6
It is assumed that the child tested is receiving a normal
diet. In only one instance did we do a quantitative stool
examination, for this is a time-consuming laboratory
method that is unnecessary and seldom done. Dr. Doro-
thy Andersen has developed a simple method of doing
a qualitative stool fat which correlates well with quanti-
tative methods.' The procedure consists in examining
under the low-power objective a small amount of stool
into which a few drops of Sudan IV have been dropped.
More than 4-5 droplets of fat per low-power field indi-
cate an excess of fat in the stool (3 plus or more). This
simple test is therefore relatively diagnostic of deficient
fat metabolism.

Vitamin A absorption is a fairly accurate index of
fat absorption from the small intestine. s>9 This test con-
sists in determining the amount of vitamin A in a fast-
ing sample of venous blood, giving 50,000 units of vita-
min A by mouth, and following this in three hours with
another vitamin A determination on venous blood.* In
a normal individual the curve should rise 150 to 200
micrograms at the end of three hours. It should be rec-
ognized that vitamin A absorption is a nonspecific test
and that the results are impaired in cretinism, jaundice,
ulcerative colitis, malnutrition, and pneumonia, as well
as in cases of steatorrhea. We have evaluated our results
in the light of this fact.

*The vitamin A absorption testing in our cases was done by
Dr. Ziegler at the University of Minnesota.

143

May, 1946

While a vitamin A curve is being done, carotene or
pro vitamin A is also determined. A low fasting level
is believed by some to be diagnostic, though this has not
proved to be true in our cases.

Sugar tolerance curves in these patients are usually
flat, revealing a deficient absorption of carbohydrate
from the small intestine. The results in this test and the
preceding tests, i.e., vitamin A and carotene, are probably
due to some defect inherent in the intestinal mucosa.

Dr. Andersen has shown that in fibrocystic disease
pancreatic trypsin and lipase are always markedly re-
duced or absent, and amylase is reduced or normal.1"
In idiopathic celiac disease there are usually no changes
in the pancreatic enzymes, except in case of starch in-
tolerance, where amylase is reduced. Dr. Andersen
showed further that the determination of pancreatic
trypsin alone is diagnostic in fibrocystic disease. Dr. An-
dersen’s method for determining the amount of trypsin
in the duodenal juice is so simple that it should be done
in every case of steatorrhea.11

In some cases fibrocystic disease may not be suspected
until pancreatic trypsin has been determined. A duo-
denal tube is passed in the morning, following a 12- to
16-hour fast. It is best to do this under fluoroscopy.
When the tip of the tube is in the ascending or trans-
verse portion of the duodenum, some duodenal juice will
usually run out and can be collected. One should dis-
card all but alkaline juice. In fibrocystic disease gentle
suction on a syringe is usually necessary to withdraw
some of the juice, for it is small in amount and sticky.
The method of determining trypsin takes about half
an hour to set up and requires no special laboratory
training.11

In our series of patients only a few show the typical
X-ray findings said to be present in gastrointestinal serial
films; that is, areas of spasm alternating with areas of
hypomotility, and the wide dilatation of many bowel
loops, the so-called segmentation or "puddling.” We
believe that this is so because so few of our patients
have had far advanced celiac disease. It is a simple mat-
ter to combine radiography with the removal of pan-
creatic juice. After sufficient juice is removed the barium
can be injected through the tube and X-rays can be
taken.

As all children with fibrocystic disease sooner or later
develop chronic respiratory infection, chest X-rays may
reveal pathology varying from markedly increased vas-
cular markings to lobular pneumonia or bronchiectasis.

In any patient in whom allergy is suspected, history
and skin tests are of course of great importance.

We believe that no single test, with the exception of
the determination of stool fat and pancreatic trypsin, is
necessarily diagnostic of the celiac syndrome. However,
the other tests offer confirmatory evidence and aid in
the differential diagnosis between the celiac syndrome
and other conditions. We have used the tests in this way
to give us a better understanding of each patient and
to suggest proper treatment. Our results, we believe,
justify our methods of arriving at a diagnosis.

Table 4 shows the results of the various tests on two
patients, one with fibrocystic disease and one with idio-
pathic celiac disease.

Results of Tests

Table 4

on Two Patients with Celiac Syndrome

Patient NQ

Patient EB

(2 months) :

( 12 months) :

fibrocystic

idiopathic celiac

Test

disease

Sugar tolerance

Fasting: 65

Fasting: 60

(mg. per cent)

2 hours: 100

2 hours: 85

3 hours: 75

3 hours: 65

Vitamin A absorp-

Fasting: 25

Fasting: 35

tion (micrograms)

3 hours: 18

3 hours: 38

Pancreatic trypsin

None present

250 units per cc.

Gastrointestinal

Normal

Segmentation,

series

puddling, and dila-
tion of small bowel

Chest X-ray

Increased markings,
lobular pneumonia
on several occa-
sions; beginning
bronchiectasis

Normal

Weight gain

At 1 month:

At 12 month:

8 pounds

15 pounds

At 24 months:

At 18 months:

22 pounds

Stool fat

Four plus

Treatment of Idiopathic Celiac Disease
Until 1942 treatment of idiopathic celiac disease was
largely dietary, i.e., starch and fatty foods were elim-
inated and the child was given mainly a high-protein
diet. Usually the protein of skimmed milk, egg whites,
meat, fish, and chicken liver was used, together with
bananas and calcium caseinate. The variety of the diet
was gradually widened in three stages, so that by the
end of six months of intensive treatment the transition
to a normal diet was usually made. There were, however,
many exacerbations, and the children and parents were
irritable a great deal of the time.

In 1942 May, McCreary, and Blackfan 3 found that
by giving alternate injections of crude liver extract and
parenteral vitamin B complex every other day for about
three weeks, and then continuing with oral vitamin B
complex, they invariably obtained a definite improvement
in the patients in three to six weeks. For convenience
we have modified their treatment with respect to the ma-
terials used (Table 5).

Table 5

Our Present Plan of Treatment of Celiac Disease

Materials Method

Crude liver extract (lcc. = 2 units)

Parenteral vitamin B complex
Each ampul of the product used
contained :

Thiamine hydrochloride
(vitamin Bi

hydrochloride) 10 mg

Riboflavin 5 mg

Pyridoxine hydrochloride .. 5 mg
Calcium pantothenate .. 5 mg

Niacinamide 50 mg

The parenteral use of crude liver extract and vitamin
B complex seems to us a great step forward in the treat-
ment of children with idiopathic celiac disease, as most
of them can resume a normal diet within six weeks, and
the cure is usually permanent. It has been our custom
to offer a high-protein and low-fat and low-carbohydrate
diet during the course of the injections, and for three

1.5 cc. intramuscularly
Q.O.D.

2 cc. intramuscularly
Q.O.D.

144

The Journal Lancet

to six weeks thereafter. Oral synthetic, i.e., yeast-free,
vitamin B complex gives the best results of any oral
B preparation.

In this series of 15 patients with idiopathic celiac dis-
ease we have obtained good to excellent results in all
patients. The children have gained weight and become
more normal mentally, have had one to two normal
formed stools per day, have been able to eat a normal
diet, and in every way have developed like normal chil-
dren. So far we have had no recurrences.

Gillman and Gillman 12 have recently described a
series of patients with infantile pellagra who had many
symptoms and signs similar to those found in idiopathic
celiac disease. As a matter of fact, they suggest that
celiac disease may be a variant of pellagra. They gave
these patients 10 grams of powdered stomach (ventric-
ulin) orally every day, together with 5 cc. of N/10
HCL. In their patients the diarrhea and steatorrhea
ceased within two to three days. This treatment has
interesting possibilities and opens up a new field for re-
search in the causes and treatment of the disease.

Treatment of Fibrocystic Disease

The present treatment of fibrocystic disease is two-
fold; that is, it is directed against the defect in the pan-
creas and against pulmonary infection. The diet con-
sists of about 180-200 calories per kilogram and is high
in protein, i.e., about 7-8 grams per kilogram. The rest
of the diet is composed mainly of carbohydrate, with
fat kept at a minimum. Eight cc. of oral vitamin B
complex per day are given. The deficiency in pancreatic
enzymes is treated by giving the child 4-6 grams of
pancreatin or pancreatic granules (about 1 level teaspoon
per meal), mixed in cereal or banana. As these children
may lose in the stools three to four times the amount
of nitrogen they absorb, it should be replaced directly
by offering pancreatin and calcium caseinate.

There is some slight amount of evidence to show that
lipocaic deficiency may have something to do with the
causation of fibrocystic disease. Browne and Thomas 13
recently treated an adult who had fatty hepatomegaly
and pancreatic fibrosis with lipocaic. The diagnosis was
proved at laparotomy. Over a period of 18 months the
liver receded and the patient’s general condition im-
proved markedly.

The problem of the pulmonary infection has not yet
been solved, but steps have been taken toward doing so.
Since the usual organism is Staphylococcus aureus, the
sulfa drugs are usually relatively ineffective. Penicillin
is effective, although the best method of giving it is not
yet known. Giving it intramuscularly will provide tem-
porary improvement, but not permanent results. Dr.
Andersen is at present giving penicillin in aerosol by
nasal catheter. The long-term results are not yet known.

We have treated four patients with fibrocystic disease.
One died at the age of three months (the diagnosis
was made at autopsy) . The other three are alive, and,
though not in perfect health, are able to lead fairly
normal lives. For exacerbations of their respiratory con-
ditions we have given them penicillin intramuscularly.

Conclusions

Every child who presents any features of the celiac
syndrome should be investigated completely. The most
reliable test in the diagnosis of idiopathic celiac disease
is the determination of stool fat. A simple method of
doing this test is described. The most valuable single
test in the diagnosis of fibrocystic disease is the deter-
mination of pancreatic trypsin in the duodenal juice.

In idiopathic celiac disease the pancreatic enzymes are
normal. The treatment of choice is the daily alternate
intramuscular injection of crude liver extract and vita-
min B complex for three weeks, followed by oral syn-
thetic yeast-free vitamin B complex, given daily until
improvement occurs. A high-protein, low-fat, low-starch
diet should be followed during the course of treatment.
Ventriculin, i.e., powdered hog stomach, in doses of
10 grams a day orally, with 5 cc. of N/10 FdCL orally
per day, has been suggested recently as a new treatment
for idiopathic celiac disease, by Gillman and Gillman,
who report good results from treatment of a small
number of patients with infantile pellagra, which may
be a related condition.

In fibrocystic disease pancreatic trypsin is invariably
markedly reduced or absent. Chronic pulmonary infec-
tion is characteristic of fibrocystic disease. Treatment
is twofold. The diet should be high in protein and
should contain added pancreatin to replace the missing
trypsin. Large amounts of vitamins A, B, C, and D
should also be given. The pulmonary infection can be
treated with penicillin, both intramuscularly and intra-
nasally in aerosol.

Bibliography

1. Farber, S.: Pancreatic Insufficiency and the Celiac Syn-

drome. New England J. Med., 229 (Oct. 28), 1943.

2. Andersen, D. H.: Cystic Fibrosis of the Pancreas and

Its Relation to Celiac Disease. Am. J. Dis. Child., 56, 344,
1938.

3. May, C. D., McCreary, J. F., and Blackfan, K. D.: Notes
concerning the Cause and Treatment of Celiac Disease. J.
Pediat., 21, 289 (Sept.), 1942.

4. Ingelfinger, F. J., and Moss, R. E.: Motility of the Small
Intestine in Sprue. J. Clin. Investigation, 22 (May), 1943.

5. Farber, S., Maddock, C., and Schwachman, H.: Pan-

creatic Function and Disease in Early Life. J. Clin. Investiga-
tion, 22 (Nov.), 1943.

6. Andersen, D. H.: Fecal Excretion in Congenital Pan-

creatic Deficiency. Am. J. Dis. Child., 69, 221 (April), 1945.

7. Andersen, D. H.: Determination of Fat in Feces in Pa-
tients with the Celiac Syndrome. Am. J. Dis. Child., 69, 141
(March), 1945.

8. May, C. D., and McCreary, J F.: The Absorption of
Vitamin A in Celiac Disease. J. Pediat., 180, 200, 1941.

9. Pratt, E. L., and Fahey, K. R.: Clinical Adequacy of a
Single Measurement of Vitamin A Absorption. Am. J. Dis.
Child., 68, 83 (Aug.), 1944.

10. Andersen, D. H.: Pancreatic Enzymes in the Duodenal
Juice in the Celiac Syndrome. Am. J. Dis. Child., 63, 643,
1942.

11. Andersen, D. H., and Early: Method of Assaying

Trypsin Suitable for Routine Use in Diagnosis of Congenital
Pancreatic Deficiency. Am. J. Dis. Child., 63, 891, 1942.

12. Gillman, T., and Gillman, J.: Powdered Stomach in

Treatment of Fatty Liver and Other Manifestations of Infan-
tile Pellagra. Arch. Int. Med., 76, 63 (Aug.), 1945.

13. Browne, F., and Thomas, W.: Fatty Hepatomegaly

with Pancreatic Fibrosis Controlled by Lipocaic. Am. J.
Digest. Dis., 12, 250 (July), 1945.

May, 1946

145

The Successful Treatment of Subacute Bacterial
Endocarditis of Children with Penicillin

George B. Logan, M.D., and Haddow M. Keith, M.D.

Rochester, Minnesota

The recent introduction of the use of penicillin in the
treatment of subacute bacterial endocarditis has very
favorably altered the prognosis of a previously almost
hopeless disease.

In 1944 Loewe and his co-workers 1 reported their
initial favorable results from the use of penicillin com-
bined with heparin. A further report J of their work
appeared a year later, as did the report of Dawson and
Hunter.3 Three children were included in these groups.

In the latter part of 1944 the first reports of success-
ful treatment of subacute bacterial endocarditis of chil-
dren with penicillin alone were published by Collins 4
and Pizzi and McCarthy.0 Bloomfield 6 reported a series
of cures as a result of treatment with penicillin alone,
but his group of patients did not include children. Since
the original preparation of this paper Flippin and his
co-workers 7 have published a series of cases in which
the disease was cured by penicillin alone. This group
included three children. Goerner, Geiger, and Blake 8
have reported another series of cases in which two of
the patients were children.

We wish to report four additional cases in which treat-
ment was successful. Preliminary reports on the first
two cases have been given by Herrell and Kennedy.9
Report of Cases

Case 1. — A nine-year-old white girl was registered at
the Mayo Clinic in June 1944 because of fatigue and
pallor of a few weeks’ duration. Two years previously
she had had a temperature of up to 101°F. for several
days, associated with pain in the upper part of the ab-
domen and aching pains in the legs. She was put to
bed for six weeks and then gradually allowed to get up
and to return to school. The aches in the legs and low-
grade fever continued. On one occasion, she became
cyanotic in the mountains at an altitude of 10,000 feet.
Her appetite was poor, but she was considered to have
much energy until shortly before her admission.

She was a small, pale girl 48 inches (122 cm.) tall
and weighing 39 pounds (17.7 kg.). The systolic blood
pressure measured 100 mm. of mercury. The diastolic
pressure was not definitely measurable. Her heart was
slightly enlarged. A systolic murmur was present, max-
imal at the aortic area.

Four blood cultures were positive for Streptococcus
viridans. In vitro this organism was inhibited in its
growth by 0.01 unit of penicillin per cubic centimeter
hut not by 0.001 unit.

The patient was treated daily for 18 days with peni-
cillin, approximately 150,000 units in isotonic saline solu-
tion, given by constant intravenous drip. A total of
2,740,000 units was administered. In addition two trans-
fusions of 125 cc. of citrated whole blood were given.

From the Section on Pediatrics, Mayo Clinic.

Blood cultures 3, 11, 21, and 25 days after the start
of treatment were negative.

Three months later her family physicians reported
that her blood culture was still negative. Fourteen
months after treatment was stopped her physician re-
ported that she was getting along well but not gaining
weight. Her last blood culture had been taken 12
months after the cessation of treatment and had been
negative.

Case 2. — An eleven-year-old white girl was brought
to the clinic in July 1944 because of congenital heart
disease and fever. A heart murmur had been detected
shortly after birth. Her activities had always been re-
stricted because of cyanosis and dyspnea.

Nine months before her admission to the clinic peri-
odic pain developed in both the upper and the lower
part of the abdomen. The pain was noted also in the
flanks and lower part of the thorax. It lasted one to two
hours and came at weekly to monthly intervals.

The patient was an irritable and apprehensive girl,
53 inches (135 cm.) tall and weighing 56 pounds
(25.4 kg.) . The blood pressure measured 106 mm. of
mercury systolic and 66 diastolic. The heart was en-
larged both to the left and to the right. A to-and-fro
murmur was present at the base. The electrocardiogram
showed evidence of right axis deviation. The circulation
time was five seconds (arm to tongue), indicating a
venous arterial shunt.

The first blood culture was reported negative after
48 hours, but showed a growth of Streptococcus viridans
in 72 hours. There were 40 colonies per cubic centimeter
of blood. In vitro this organism showed growth in 0.01
unit of penicillin per cubic centimeter, but no growth in
0.1 unit per cubic centimeter.

Treatment with a continuous intravenous drip of peni-
cillin in isotonic saline solution was begun and continued
for 21 days. Approximately 90,000 units were given
daily. A total of 1,900,000 units was administered.

On the day treatment was begun the blood culture
was reported to be negative. The blood cultures were
negative 14, 21, 24, and 31 days after the start of the
treatment.

Within three months the patient was able to return
to school part time. Thirteen months later her home
physician reported that the girl’s blood culture was still
negative.

Case 3. — A nine-year-old white girl was brought to the
clinic in February 1945 because of abdominal pain, rapid
pulse, and vomiting.

Three years previously, in 1942, she had had scarlet
fever, chickenpox, and measles in close succession. Since
that time her physician had known that she had a heart
murmur.

146

The Journal Lancet

R Days

+ = Positive blood culture for Streptococcus viridans
° = Negative blood culture

Fig. 1. Treatment and coarse of Case 3.

In November 1944 she had had a cold and a sinus
infection, followed in three weeks by pain in the right
elbow and shoulder. After that she had migratory arthri-
tis involving the fingers, toes, hips, and elbows. Her
temperature rose daily, at times to 104° F. She was kept
in bed and given salicylates and codeine.

A few weeks prior to entry abdominal and precordial
pain had been noted. At the time of admission she par-
ticularly complained of pain in the left upper quadrant
of the abdomen. An attempt at digitalization had been
unsuccessful.

The patient was a well-developed, well-nourished, very
co-operative girl. The heart was enlarged to the left,
and a loud, rough, widely transmitted systolic murmur
was present at the apex. The edge of the spleen was
palpable at the costal margin.

The hemoglobin measured 10.7 gm. per 100 cc. of
blood. Erythrocytes numbered 4,320,000 and leukocytes
11,600 per cubic millimeter of blood.

The blood culture was positive for Streptococcus viri-
dans; there were 100 colonies per cubic centimeter of
blood. In vitro this organism was killed by 0.1 unit of
penicillin per cubic centimeter, but not by 0.01 unit.

Administration of penicillin was begun, and 90,000
to 150,000 units per day were given (Fig. 1). Some of
it was administered intravenously and some intramuscu-
larly. A total of 2,300,000 units was given. The day
following the start of treatment the patient had an
embolus in the skin over the right eyebrow. Two weeks
later she had emboli in the right knee and the toes of
the right foot. Fifteen and 17 days after treatment was
started she had episodes of very severe precordial pain.

Six months later her general health was good. The

cardiac murmur was present but her blood culture was
negative and her sedimentation rate was normal.

Case 4. — An eleven-year-old white girl was brought to
the clinic in May 1945 because of a sudden onset of
right hemiplegia. It was difficult to obtain an accurate
history. She had apparently been in good health until
five weeks before entry, when she had had a chill and
fever which lasted one day. Since that time she had had
increasing fatigue. Three weeks previously pain in the
right shoulder, frontal headaches, and pain in the left
upper quadrant of the abdomen had developed. She
was treated by a chiropractor with some temporary bene-
fit. He discovered that she had a cardiac murmur. At
this time her parents noted that in the afternoon she
had a temperature of 102° to 102.6° F. In the three
days prior to admission she had two or three brief spells
of dizziness of about fifteen seconds each. On the day
of entry, while she was drying dishes, she suddenly be-
came dizzy and slumped to the floor. When she tried
to get up she noted her inability to use her right arm
or leg.

She was a pale, co-operative girl, who had a flaccid
paralysis of her right side, except for the muscles of the
forehead. The deep reflexes were increased on the right
and the Babinski sign was positive on that side.

The heart did not appear to be enlarged. A loud,
rough systolic murmur was present throughout the pre-
cordium, maximal at the apex. The spleen was palpable.

The patient had a number of involuntary urinations.
The electro-encephalogram showed evidence of a lesion
in the left motor temporal area. The cerebrospinal fluid
was clear. The total protein was 45 mg. per 100 cc.,
and there were 8 lymphocytes per cubic millimeter of

May, 1946

147

fluid. The hemoglobin measured 12.1 gm. per 100 cc.
of blood. Erythrocytes numbered 4,200,000 per cubic
millimeter and leukocytes 11,400, of which 83 per cent
were polymorphonuclear leukocytes. Roentgenograms of
the thorax and skull were reported as normal. Exam-
ination of the ocular fundi was also reported as giving
normal results.

The initial blood culture showed 30 colonies of Strep-
tococcus mitis per cubic centimeter of blood. A second
culture four days later showed 25 colonies of the same
organism per cubic centimeter. No in vitro tests against
penicillin were carried out.

An intravenous drip of penicillin in isotonic saline
solution was started on the day the second blood culture
was obtained. Fifty thousand to 200,000 units were ad-
ministered daily. A total of 2,285,000 units was given
in a 21-day period. The blood cultures on the 8th, 17th,
24th, and 38th day after the start of treatment were all
negative.

Physical therapy, consisting chiefly of baking, mas-
sage, and passive motion, was started soon after admis-
sion. The patient showed a little improvement in the
use of her right side before dismissal on the 44th hos-
pital day.

Three months later her blood culture was negative.
She was able to be up in a wheel chair. Progress in re-
gaining the use of her right side was very slow.

Comment

As a result of our experience and that of others, we
do not feel that heparin is a necessary adjuvant to peni-
cillin in the treatment of patients having subacute bac-
terial endocarditis. In fact, some authors 10 have ex-
pressed the opinion that the use of heparin adds unwar-
ranted risk to the treatment.

It is wise to carry out an in vitro test of the effect
of penicillin on the organism encountered in each case.
The reasons for doing so are obvious.

We arbitrarily started out to give intravenously to
each of these patients 150,000 units of penicillin daily.
Technical and personality factors forced some variations
in this dosage. Thus, in Case 1 the patient received
2,740,000 units instead of 3,150,000; in Case 2, 1,900,-
000; in Case 3, 2,300,000; and in Case 4, 2,285,000
units. Apparently, under the conditions encountered in
our cases these doses were adequate.

It is essential that the antibiotic agent be given con-
tinuously as an intravenous drip or at three-hour inter-

vals by the intramuscular route. Continuous intramus-
cular administration should be satisfactory as well. In
Case 3 the latter method was used part of the time,
but the apparatus employed was not satisfactory. It is
also essential that penicillin be administered for a long
enough period. Our three-week period was arbitrarily
determined. Other successful reports have mentioned
periods of only two weeks. Adequate dosage, continu-
ous administration, and prolonged duration are the key-
notes of treatment.

Bloomfield has written of the occurrence at times of
emboli during treatment. We noted the occurrence of
emboli two weeks after the start of treatment in Case 3.
In that instance, at least, the three-week period of treat-
ment was desirable.

The physician must remember that when he supervises
the cure of subacute bacterial endocarditis he is still
faced with the care of a cardiac invalid, and at times
with that of a hemiplegic patient.

References

1. Loewe, Leo, Rosenblatt, Philip, Greene, H. J., and Rus-
sell, Mortimer: Combined Penicillin and Heparin Therapy of
Subacute Bacterial Endocarditis; Report of Seven Consecutive
Successfully Treated Patients. J AM. A., 124: 144 (Jan. 15),

1944.

2. Loewe, Leo: The Combined Use of Anti-Infectives and

Anticoagulants in the Treatment of Subacute Bacterial Endo-
carditis. Bull. New York Acad. Med., 21: 59 (Feb.), 1945.

3. Dawson, M. H., and Hunter, T. H.: The Treatment of
Subacute Bacterial Endocarditis with Penicillin; Results in
Twenty Cases. J.A.M.A., 127: 129 (Jan. 20), 1945.

4. Collins, B. C.: Subacute Bacterial Endocarditis Treated

with Penicillin. J.A.M.A., 126:233 (Sept. 23), 1944.

5. Pizzi, F. W., and McCarthy, F. W.: Subacute Bacterial
Endocarditis Successfully Treated with Penicillin. U. S. Nav.
M. Bull., 43: 1010 (Nov.), 1944.

6. Bloomfield, A. L., Armstrong, C. D., and Kirby, W. M.

M.: The Treatment of Subacute Bacterial Endocarditis with

Penicillin. J. Clin. Investigation, 24: 251 (May), 1945.

7. Flippin, H. F., Mayock, R. L., Murphy, F. D., and Wol-

ferth, C. C.: Penicillin in the Treatment of Subacute Bac-

terial Endocarditis; a Preliminary Report on Twenty Cases
Treated over One Year Ago. J.A.M.A., 129: 841 (Nov. 24),

1945.

8. Goerner, J. R., Geiger, A. J., and Blake, F. G.: Treat-
ment of Subacute Bacterial Endocarditis with Penicillin: Re-

port of Cases Treated without Anticoagulant Agents. Ann.
Int. Med., 23: 491 (Oct.), 1945.

9. Herrell, W. E., and Kennedy, R. L. J.: Penicillin: Its

Use in Pediatrics. J Pediat., 25:505 (Dec.), 1944.

10. Meads, Manson, Harris, H. W., and Finland, Maxwell:
The Treatment of Bacterial Endocarditis with Penicillin; Ex-
periences at the Boston City Hospital during 1944. New Eng-
land J. Med., 232: 463 (Apr. 26), 1945.

148

The Journal Lancet

The Use of General Anesthesia in the Treatment of
Extensive Caries in Problem Children

Ralph T. Knight, M.D., Joseph T. Cohen, D.D.S., and M. M. Litow, D.D.S.

Minneapolis

Part I. The Anesthetist’s Problem, by Ralph T. Knight, M.D.

One of the anesthetist’s greatest problems is the selec-
tion and proper administration of anesthetics for
children. A child’s nervous system is much more irrita-
ble and unstable than that of an adult. A child’s brain
succumbs to relatively small doses of sedatives and anes-
thetics. The spinal reflexes and the reflexes of the brain
stem are tremendously active and tremendously resistant
to anesthetics, and the activity and resistance are rela-
tively unpredictable. With many of our anesthetics doses
large enough to quiet and control peripheral reflex activ-
ity are simply overwhelming to the child’s brain.

Ether is a relatively weak anesthetic that requires high
blood concentration to produce anesthesia, and it is there-
fore slow in action. However, its effect is long in dura-
tion and its maintenance relatively even and stable. For
this reason it has remained the favorite anesthetic for
children. Mechanical difficulties in administering other
anesthetics to children have also discouraged their use.
Veins are often small and easily injured. If one is de-
pending upon the placement of the needle to maintain
anesthesia and the vein is spoiled, one is confronted im-
mediately with an embarrassing, even distressing, emer-
gency.

The administration of gases to children has usually
been considered unwise or impracticable, because chil-
dren do not tolerate well the necessity for breathing
through tubes with increased resistance. Most anes-
thetists have therefore fallen back on what seems the
simpler method of open-drop administration of ether.

The arguments against the use of ether are: (1)

it causes much more postanesthetic illness and prostra-
tion; (2) it tends to produce acidosis; (3) it does not
lend itself well to all situations with relation to the
mechanics of surgery.

The difficulties with other anesthetics, already men-
tioned, are more apparent than real and may be over-
come with care and skill.

Because of the child’s unstable nervous system anes-
thesia is, to say the least, touchy. Touch-and-go situa-
tions arise much more frequently in dealing with chil-
dren than with adults. The risk is therefore greater.
When deciding upon administering anesthesia for a
procedure that will add to the patient’s welfare but is
perhaps not a necessity, one must evaluate the probable
benefit against the possible risk. Tonsillectomy, for in-
stance, though usually not an immediate necessity, in
many cases distinctly promotes the child’s welfare. It
is considered by most to be a relatively minor surgical
procedure. Nevertheless, the incidence of anesthetic
accidents and even death is much higher in tonsillectomy
than in any other surgery.

Dr. Cohen has pointed out the great value for the
child’s welfare in having extensive dental caries repaired.
Such repairs are of such great value that they might
even be considered a real necessity. He has also pointed
out the great difficulty and even impossibility in many
cases of performing such repairs with the patient con-
scious. The question then arises: shall the child be sub-
jected to anesthesia, and is the relatively small anesthetic
risk justifiable in relation to the need for the dental pro-
cedure? If so, certainly every precaution must be taken
to minimize the risks.

The risks involved are (I) obstruction of the respira-
tory tract mechanically; (2) obstruction of the respira-
tory tract or soiling by the inhalation of secretions and
debris; (3) respiratory depression or arrest due to the
anesthetic; (4) the danger of flame or explosion.

Over a prolonged period of time, with the mouth
propped open, the tongue often pushed back, and drill-
ing, scraping, and chipping going on, it is a practical
impossibility, by ordinary means, to avoid obstructing
the airway and to prevent the entrance of debris into the
glottis. By ordinary methods, also, any inhalation anes-
thetic will be present in the mouth, where sparks caused
by static or friction may ignite it. All inhalation anes-
thetics except nitrous oxide and chloroform are inflam-
mable, and neither of them is suitable for prolonged
administration.

All the above risks may be practically eliminated by
inserting an intratracheal tube, equipped with an in-
flatable cuff to make a gas-tight connection between the
anesthesia machine and the trachea. The air with which
the cuff is inflated is kept balanced with a manometer,
and the pressure is maintained at 15 cm. of water, which
is effective but safe. By this means gases such as eth-
ylene and cyclopropane can be employed, with adequate
oxygen, for a long period of time. They can be much
more delicately controlled than ether.

This technique can be used effectively in children
down to 3 years of age, and children who need extensive
dental repair are seldom younger. With the tube in
place the airway is always open, debris cannot enter, gas
and vapor do not escape, and the other danger, that of
respiratory depression, can always be cured by manual
bag respiration. This method prevents accidents from
overdose.

For oral surgery the tracheal tube is frequently in-
serted through the nose to put it entirely out of the way
of the surgeon. However, children’s noses are rather
easily traumatized. In all the cases in this group the
tube was therefore inserted orally, and Dr. Cohen found
it possible to work very well with the tube in one corner

May, 1946

Table 1

Multiple Dental Restorations under General Anesthesia

149

Anesthetic Premedication

Number of

Kind

Duration

Mor-

Scopola-

Reason for

Date

Name

Sex

Age

Fillings

(minutes)

phine

mine

Choice

Results

(grains)

9/5/45

2-11

Cyclopropane

120

1/32

1/800

Age

Good

8/2/45

3-1

Cyclopropane

1/32

1/800

Age

Good

3/13/45

3-6

Cyclopropane-
Nitrous Oxide

1/32

1/800

Age

Good

9/6/44

4-6

Cyclopropane

1/32

1/800

Mental

Good

1/10/45

4-6

Cyclopropane

123

1/32

1/800

Mental

Fair

5/5/45

4-6

Cyclopropane

130

1/24

1/800

Age

Good

8/9/45

4-11

Cyclopropane-
Nitrous Oxide

1/32

1/800

Age

Good

8/9/45

5-11

Cyclopropane-
Nitrous Oxide

1/32

1/800

Age

Good

5/21/45

8-9

Cyclopropane

1/16

1/400

Frightened

Good

3/31/45

9-3

Pentothal-Nitrous
Oxide— Ethelene

120

1/8

1/250

Mental

Good

3/7/45

17-0

/ 7

\ X-rays

I Prophylaxis

Pentothal-
Nitrous Oxide

1/6

1/200

Spastic

Good

AVERAGE

. 6-11

15.7

102

of the mouth. All the work on one side of the mouth
was finished, and then the tube was changed to the other
corner so that the other side could be repaired. This
method possibly caused a little inconvenience, but Dr.
Cohen seemed to become well adjusted to it.

Table 1 gives the age, premedication, kind and dura-
tion of anesthetic used, and other details of each case
in this group.

The anesthetic agents used were cyclopropane, eth-
ylene, nitrous oxide, and pentothal. Cyclopropane was
used in nine of the cases and was the agent chiefly
relied upon. Three of the cyclopropane cases, after the
anesthesia had been well established, were carried for a
considerable part of the time with nitrous oxide, admin-
istered in such a way that at least 30 per cent oxygen
was constantly in the respired atmosphere. In all these
cases the nitrous oxide proved insufficient from time to
time and had to be supplemented with small additions
of cyclopropane.

The two oldest children, aged 9 and 17, were anes-
thetized with pentothal. The 9-year-old child then re-
ceived 70 per cent nitrous oxide with 30 per cent oxygen,
except for a short time when ethylene was substituted.
This child received a total of only 250 milligrams of
pentothal in two hours; the pentothal was used in very
small quantities from time to time as needed to supple-
ment the nitrous oxide or ethylene. The 17-year-old
child received 70 per cent nitrous oxide with 30 per cent
oxygen, and required a supplement of 750 mg. of pen-
tothal over a period of one hour and twenty minutes.
Both these children were intubated under the initial pen-
tothal anesthesia.

Older children are much better candidates for pen-
tothal than younger ones, for their brains are much less
prostrated by it. With the nitrous oxide, and in one
case ethylene for a short time, it was possible to use a
minimum of pentothal, allowing the children to awaken

rapidly. With this combination it was possible in these
two instances to avoid any explosive mixtures, except for
a very short time in the one case.

All the other nine children, therefore, were subjected
to an explosive anesthetic throughout the whole period.
There is no way to avoid this risk except to administer
the anesthetic by rectum. The only agents suitable for
this method are avertin and ether-in-oil. Both produce
prolonged anesthesia, with considerable depression fol-
lowing, and I believe increase the risk in other ways.
The intratracheal tube is again our greatest defense
against this risk.

Blood pressures and pulses were taken and recorded
at five-minute intervals in all these patients. There was
a tendency toward a slight rise in blood pressure. In
four cases there were rises in systolic blood pressure
of 10 to 30 mm. of mercury over the preanesthetic
level. In four cases there were falls in systolic blood
pressure ranging from 5 to 10 mm. of mercury. There
was no significant change in any of the diastolic pres-
sures. Most of them followed the systolic, but to a less
degree. The pulses remained remarkably stable, and
changed hardly at all from the preanesthetic rate.

Most of these children woke up very promptly upon
the discontinuance of the anesthetic. They were kept
in the hospital for an average of four hours until they
could be taken home by the most convenient method.
Nausea was at a minimum. In those children who were
nauseated at all it was only for a few minutes after they
awakened. A 4-year-old child who had extractions in
addition to repairs inhaled some blood after removal of
the intratracheal tube and had a period of acute stridor.
I inserted a 16-gauge suction catheter under direct vision
and sucked out what appeared to be all the inhaled
material. The stridor was much relieved, but there was
still some difficulty in breathing, and it appeared that
some material had been inhaled into one of the bronchi.

150

The Journal Lancet

Suction bronchoscopy was suggested, but the child
seemed to be improving. He remained in the hospital
two or three days, and was finally able to cough out the
remaining material without further ill effect. This acci-
dent, which occurred while the child was still uncon-
scious, emphasizes the need for careful packing and
careful cleansing of the child’s mouth and throat by
both dentist and anesthetist.

All the patients received preanesthetic medication con-
sisting of morphine and scopolamine. The dose ranged
from 1/32 of a grain of morphine for the 3- and 4-
year-olds to 1/8 grain for the 9-year-old and 1/6 grain
for the 17-year-old. The scopolamine dose ranged from
1/800 to 1/200 of a grain.

These doses varied not only according to age, but also
according to the size and vigor of the patient. For in-
stance, the 5-year-old patient received 1/32 grain of
morphine and 1/800 grain of scopolamine, while one
of the 4 54 -year-olds received 1/24 grain morphine and
1/ 600 grain scopolamine. Children take morphine very
well, in larger proportional doses than adults according
to size. This drug makes the patient much more quiet
and receptive to anesthesia and makes the anesthetic
control much easier and safer. The scopolamine con-
tributes to the hypnosis and stops the troublesome secre-
tion of mucus in the respiratory tract and saliva in the
mouth. Dr. Cohen has found premedication with sco-
polamine to be of great assistance to him in his dental
work.

Scopolamine gives an occasional child an adverse re-
action, but the chance is well worth taking in view of
the great benefit received by all the patients. A bella-
donna rash in itself is of no consequence. However,
if the pulse rate and body temperature are raised to any

marked degree the anesthesia should be postponed. The
hypodermic must be given at least 45 minutes before
starting anesthesia. If it has not been given sufficiently
early the anesthesia should be delayed until 45 minutes
have elapsed. If it can be learned that the hypodermic
has not been given and there are not 45 minutes re-
maining, the medication should be delayed until a few
minutes before starting the anesthesia and then should
be administered intravenously.

A combination of pentothal, curare, and nitrous oxide
has been used very successfully at the University of
Minnesota in many types of surgery for older children
and adults. It is possible that we may extend this meth-
od downward to the younger children, thus eliminating
one of the appreciable hazards, which is that of explo-
sion. A 7-year-old girl was given this combination for
fixation of a fracture of the maxilla and debridement
of lacerations of the face, and a 5-year-old girl for
recession and resection of the muscles of the eye.

Summary

Eleven children were given anesthesia for periods of
one hour, ten minutes to two hours, ten minutes for
extensive repair of dental caries. The anesthetics used
were cyclopropane, ethylene, nitrous oxide, and pentothal
sodium. The risks of respiratory obstruction, inhalation
of foreign material, over-deep anesthesia, and explosion
of inflammable anesthetics were minimized by the use
of the intratracheal tube. All the patients were premedi-
cated with morphine and scopolamine. It should be un-
derstood that with all the precautions applied there is
still a definite, though slight, risk in the administration
of any anesthetic for any purpose. This risk must be
balanced against the necessity of, and the benefit to be
derived from, the work that calls for the anesthesia.

Part II. Treatment of Extensive Caries in Children under General Anesthesia,
by Joseph T. Cohen, D.D.S., and M. M. Litow, D.D.S.

This is a report of the use of general anesthesia as
an aid in restoring, in one sitting, many broken down
and decayed teeth in young children. This method is
now in the experimental stage and must be limited to
carefully selected cases with numerous cavities. It should
be advised only when the regular dental office routine
is contraindicated because of lack of co-operation of the
patient. This lack of co-operation may be due to an
underdeveloped mentality or to the extreme youth of
the patient.

Consultation with the child’s physician is imperative
before deciding in favor of this plan of procedure. Be-
cause the anesthetic will probably be maintained from
one to two hours the child should be in good health and
the respiratory organs and the heart must both function
properly. The patient should be hospitalized the evening
preceding the operation and premedicated at the proper
time before the anesthetic is given.

Dr. Ralph Knight and we collaborated on 1 1 cases in
the dental clinic at the University of Minnesota Hos-
pital. There were 9 girls and 2 boys, ranging in age
from 2 years, 11 months to 17 years; the average age

was 6 years, 11 months. Actually, 7 of the 11 children
were 4 years of age or less. The number of cavities filled
per child ranged from 7 to 24; the average was slightly
over 15 fillings for each case. Dr. Knight administered
the anesthetic while we gave the teeth and surrounding
tissues whatever dental attention was deemed necessary.

In some cases it may be advisable to complete only
the simple cavities and the painful portion of the diffi-
cult ones under the anesthetic. The incompleted cavities
may be filled at a subsequent visit. All operative pro-
cedures must be undertaken with deep consideration for
and gentleness to the surrounding tissues. All carious
tooth substance must be thoroughly removed, the cavity
dried and sterilized, and the restoration inserted as care-
fully as when no anesthetic is used.

Of the 1 1 cases operated on, only one developed into
a problem. It was the second patient — a girl 4 years,
6 months of age, with 17 cavities to be filled and 2 teeth
to be extracted. She apparently inhaled some blood,
which lodged in her trachea and caused considerable irri-
tation, coughing, and difficult breathing. She remained
in the hospital several days until she eventually coughed

May, 1946

151

up the blood clot. Her condition then immediately im-
proved, and she was dismissed and returned home. This
experience taught us that when teeth are extracted it is
wise to stop all bleeding before discontinuing the anes-
thetic. The remaining 10 cases left the hospital in the
middle of the afternoon following the anesthetic.

Conclusions

The following precautions should be carefully observed
and followed:

1. The cases should be carefully selected.

2. This method should be used only when other means
are inadvisable.

3. Patients need a thorough physical examination.

4. All particles of excess filling material must be care-

fully and completely removed from the floor of the
mouth before discontinuing the anesthetic.

The disadvantages encountered in this method are:

1. Need of hospitalization.

2. Prolonged anesthesia for young children.

3. The operator must work rapidly and under pres-
sure.

The advantages are:

1. General anesthesia provides a means of dental care
for some children who would otherwise be neglected.

2. It saves the time of the operator and saves many
dental appointments for the patient.

3. Many difficult and painful dental operations can
be completed in one operation.

4. It minimizes the child’s fear of dental procedure.

AMERICAN STUDENT HEALTH NEWS

Dr. Charles Shepard, former president of the American Student Health Association,
and for many years active in student and public health, is convalescing from a recent opera-
tion at the National Naval Medical Center. His present address is 2002 Testle Street, Palo
Alto, California.

Dr. Wilbur C. Smith has been appointed director of student health at the University
of Wyoming, Laramie, Wyoming.

Dr. Florence Gilman has recently resigned from the staff of Smith College. Dr. Marion
F. Booth has been appointed college physician to replace her.

Dr. A. A. Lyman, for many years director of student health at the University of
Nebraska, has retired.

Dr. John H. Rathbone of the College of Physicians and Surgeons in New York, has
been appointed director of student health and university physician at Colgate University.

Dr. B. A. Leddy, a graduate of Harvard Medical School in 1924, who has been on the
staff of the student health department of Yale University for the last eighteen years, is
available for a position on the staff of a university or college health service. His address is
Department of Health, Yale University, New Haven, Connecticut.

152

The Journal Lancet

Mesenteric Cysts Causing Intestinal Obstruction

in Infancy

Report of Two Cases

L. G. Pray, M.D.

Fargo, North Dakota

Mesenteric cysts are relatively uncommon.1,2 Their
status has probably been clarified best by Ladd and
Gross,3 who also report eight cases from the Boston
Infants’ and Children’s Hospital.

Although present during infancy, these cysts grow
slowly and are usually not detected until later in the
first decade. In the typical case a slowly enlarging, pain-
less abdomen is the only complaint. In other cases there
are recurring attacks of mild to moderate abdominal
pain, which may be associated with vomiting; the ab-
dominal pain lasts only a day or two, and recurs at
infrequent intervals; there may be poor weight gain and
loss of appetite. In rare instances there are symptoms
of acute intestinal obstruction if the cyst exerts much
pressure on the gut.

In some cases the diagnosis can be made preopera-
tively, but this is not always true. A mesenteric cyst
may or may not be palpable through the abdominal wall,
depending on its size and tenseness. X-ray films of the
abdomen, with or without a barium meal, often but not
always reveal a gasless shadow which displaces intestines
into other parts of the abdomen. X-ray studies help to
differentiate mesenteric cysts from omental cysts, in
which the gasless shadow lies in front of the intestines
instead of displacing them from their normal position.

In uncomplicated cases the cyst may be dissected out
from the mesentery. As an alternative method of treat-
ment the cyst may be marsupialized, but Ladd does not
recommend this procedure. If the intestine is gangrenous,
or the cyst is adherent to the intestine, excision of the
cyst and adjacent intestine must be done and anastomosis
performed.

Mesenteric cysts must be differentiated from enteric
cysts (duplications). The duplication cannot be removed
without destroying the blood supply and injuring the
muscular coat of the adjacent segment of intestine;
it is a thick-walled structure lying in the mesentery close
to the bowel. Mesenteric cysts, on the other hand, have
thin walls, which on microscopic examination are seen
to consist of connective tissue, with a layer of flattened
endothelial cells on the inner surface.

Mesenteric cysts are usually single and unilocular;
they may become as large as a grapefruit, or even larger.
They lie between the peritoneal leaves of the mesentery,
and tend to have a dumbbell shape; they are usually not
tensely filled. They probably arise from misplaced bits
of lymphatic tissue. They grow slowly. They are most
common in the mesentery of the jejunum or ileum, but
may rarely appear in the transverse mesocolon and in the
mesosigmoid. The cysts may be chylous or serous; the

*From the Fargo Clinic and St. Luke’s Flospital.

chylous cysts usually arise from the mesentery of the
jejunum, where the material draining from the intestinal
tract contains a higher percentage of fat.

Report of Cases

Case 1. Baby K. S., St. L. No. 76916, aged eight
weeks, was admitted to St. Luke’s Hospital at 1:30 a.m.
on April 2, 1945, because of persistent vomiting and
recurrent attacks of pain and crying for the previous
22 hours, occurring about every 15 minutes since then.
The vomitus had been bile stained, and for several hours
prior to admission had been fecal in character; it was
not projectile. There had been no bowel movements
since the onset of symptoms. The baby was taken to
the local doctor, who referred him to our care.

The infant was critically ill. The temperature was
104.4° F. rectally. The tissues were markedly dehydrated
and malnourished; the eyes and anterior fontanel were
sunken. The skin was pale. The abdomen was mod-
erately distended. There was an abdominal mass slightly
below and to the right of the umbilicus; on palpation
it felt to be about the size of an orange, and was fairly
firm in consistency and movable in the peritoneal cavity.
Rectal examination revealed no abnormalities, and no
mucus or blood was expelled following removal of the
examining finger. The remainder of the physical exam-
ination was essentially normal, except for a moderate
umbilical hernia.

The baby weighed 10 pounds at birth. He was breast
fed at first, but was put on formula because of vomiting
and failure to gain weight. He had gained no weight
since birth. The vomiting was intermittent and not
projectile. The mother was in good health. The father
was also well except for chronic arthritis. There was
one sibling, who was in good health.

The patient was immediately given an intravenous
scalp vein infusion of 150 cc. of 5 per cent glucose in
Ringer’s solution. A blood count was done shortly after-
ward. Erythrocytes numbered 3,970,000, hemoglobin
11.4 grams, leukocytes 11,700, with the following differ-
ential: neutrophiles 77, lymphocytes 18, and monocytes 5.
X-ray films were taken of the large bowel following
barium enema. They showed the cecum and ascending
colon displaced by an extrinsic mass in the right ab-
domen (Figure 1).

The patient was given a preoperative injection of
atropine sulphate 1/ 1000 grain, and was taken to the
operating room at 3 a.m. Drop ether was the anesthetic
used, as sparingly as possible, but in sufficient amount
to keep the baby quiet during the entire operation, which
lasted for 75 minutes. Lactate Ringer’s solution was ad-
ministered subcutaneously in the thighs during opera-

May, 1946

153

tion. Adrenalin chloride 1:1000, 2 minims, was given
once during the operation.

Dr. V. G. Borland carried out the surgical treatment.
A right rectus incision was made in the lower abdomen.
When the peritoneal cavity was opened a milky fluid
escaped. On exploration several chylous cysts were
found in the mesentery adjoining the upper ileum. The
largest of these was 5 or 6 cm. in diameter, and com-
pressed a segment of small intestine which was obviously
gangrenous. This cyst bulged out on both sides of the
mesentery and had the dumbbell shape characteristic
of these lesions. The other cysts, four or five in number,
were smaller, and lay close to the base of the mesentery.
About 5 inches of small intestine were excised between
forceps, together with a V-shaped portion of the mesen-
tery which contained the cysts. The vessels of the mesen-
tery were ligated with fine silk. A closed end-to-end
anastomosis was then made; two rows of sutures were
used, of which the inner was chromic 0000 catgut and
the outer was interrupted sutures of silk. The site of the
anastomosis was sprinkled with sulfanilamide crystals.
The wound was then closed without drainage, with in-
terrupted silk in the peritoneum and posterior and an-
terior sheaths and silk in the skin.

The postoperative condition was poor. The pulse was
rapid and thready and the respirations rapid and shal-
low; the temperature was 97.2° F. rectally. The foot
of the bed was elevated, and the bed was warmed with
hot water bottles. Coramine, 3 minims, was given hypo-
dermically shortly after the baby was returned from the
operating room.

The baby’s condition remained critical during the rest
of the night. Subcutaneous lactate Ringer’s solution was
resumed after the baby had been back in his bed for
about an hour. At 7:30 a.m., 3 hours and 15 minutes
after completion of surgery, a scalp vein transfusion
of 100 cc. of citrated blood was given. The abdomen
was becoming distended, and so continuous nasal suction
by the Wangensteen method was started.

It soon became evident that the condition of the pa-
tient was not improving. A ureteral catheter was inserted
into an ankle vein, and fluid balance was maintained by
continuous intravenous drip for the next 4 /i days. The
fluids given by this route consisted of glucose solution,
Ringer’s and lactate Ringer’s solutions, normal saline
solution, plasma, and citrated blood. Penicillin was
added to the solutions in the amount of 50,000 units
the first day and 20,000 units daily thereafter. Within
three or four hours after the continuous drip was started
the patient’s color and general condition began to im-
prove visibly; within 36 hours he appeared to be out of
danger. The Wangensteen nasal suction was continued
for over three days, when it was removed and formula
feedings were begun cautiously. The following day,
April 6, the catheter was removed from the ankle vein.
Considerable swelling and redness of the leg and thigh
had occurred by that time, but it promptly subsided after
fluids by this route were discontinued.

The patient was discharged from the hospital on
April 27 weighing 10 pounds, 11 ounces. When next

Fig. 1. Case 1. X-ray film of abdomen following barium
enema, showing gasless shadow on the right with displacement
of bowel to the left.

seen, on June 5, he weighed 14 pounds, 1 ounce, and
was progressing normally in every way.

Case 2. Baby C. O., St. L. No. 78582, was born on
March 29, 1945. Delivery was spontaneous. Birth weight
was 8 pounds, 4 ounces. The mother had a normal
pregnancy and labor. The mother and father were in
good health. A sibling had died at three days of age
as a result of a lumbar spina bifida with meningocele.
The patient had a normal neonatal period. She was
taken off the breast at one month of age and put on
an evaporated milk formula.

I first saw the infant on May 29, 1945, when she
was two months old. The mother stated that the baby
had been well until the previous day, when she vomited
several times and was constipated. On examination the
baby did not appear ill. Her weight was 1 1 pounds,
8 ounces. The rectal temperature was 99.4° F. The body
length was 23 inches. All physical findings were entirely
normal except for a moderate umbilical hernia, which
was strapped. There were no abdominal masses and
no distention.

The infant did well until 18 days later, when she was
again brought in because of colic, constipation, and vom-
iting for one day. Physical findings were again normal;
the baby’s color and nutrition were good.

154

The Journal Lancet

On July 23, 1945, at a little under four months of
age, the baby was seen because of high fever for two
days and vomiting and diarrhea for one day. The intake
had been poor for the previous month. The vomitus on
the morning of admission to the hospital was bile stained.
The erythrocytes numbered 3,510,000, hemoglobin 9.6
grams, leukocytes 16,550, neutrophiles 56, lymphocytes
42, and monocytes 2. The urine showed a trace of albu-
min, but was otherwise negative. The infant looked
pale and irritable and was somewhat undernourished and
dehydrated. The rectal temperature was 101 F. The
body weight was 11 pounds, 15 ounces. The abdomen
was moderately distended; no masses were palpated; the
small umbilical hernia was present. There was a coarse
miliarial rash on both arms. The physical findings were
otherwise negative.

The patient was given fluids subcutaneously; nourish-
ment by mouth was withheld temporarily and then start-
ed cautiously in small amounts. X-ray examination of
the abdomen on the day of admission revealed no evi-
dence of intestinal obstruction. The baby continued vom-
iting and was maintained on parenteral fluids. Continu-
ous nasal suction was employed. The temperature drop-
ped to normal by the third hospital day.

X-ray examination of the stomach and small bowel
was made on July 27, the fifth hospital day. It showed
evidence of almost complete obstruction in the first loop
of jejunum near the midline; there was no displacement
of peritoneal contents, and the obstructing lesion was
thought to be nontumefactive, probably a mesenteric
band or adhesion.

Surgical treatment was carried out the following day.
The baby was prepared by administration of fluids and
a scalp vein transfusion of citrated blood. The stomach
was lavaged preoperatively. Atropine, grains 1/1000,
was given hypodermically. Drop ether anesthesia was
used. Dr. N. Tronnes performed the operation, assisted
by Dr. W. F. Baillie. When the peritoneal cavity was
opened through an upper right rectus incision, jejunal
coils came into view, some of which were dilated. Upon
traction three large chylous cysts came into view; one
was the size of an orange, and the other two were a
little smaller; all three were firmly adherent to the jeju-
num. There were a number of enlarged mesenteric
lymph glands in the adjacent region. A resection was
done of 4 inches of gut, including the chylous cysts. A
side-to-side anastomosis was made. The baby’s condition
was good at the completion of surgery, which lasted for
95 minutes from the time of starting the anesthesia.

Penicillin, 5000 units every three hours, was given for
the next three days. Nasal suction was employed for
three days postoperatively. A blood transfusion was
given on the day following surgery, and again six days
later. Parenteral fluids were administered daily until the
baby was taking adequate amounts of fluids by mouth.
By the fourth postoperative day the baby was taking
nourishment fairly well, and her course thereafter was
uneventful. Four days before discharge her erythrocyte
count was 5,860,000 and her hemoglobin 15.6 grams.

She was discharged on the 29th hospital day, weighing
12 pounds, 2 ounces. Dr. Eleanor Iverson gave valuable
assistance in the general care of this infant.

The baby was readmitted to the hospital on August
30, 1945, because of an upper respiratory infection with
diarrhea. She responded well to treatment, and remained
in the hospital only two days. She was last examined on
December 4, 1945, at the age of eight months. She
weighed 19 pounds, 1 ounce, and was 27 inches in
length. All physical findings were normal. X-ray exam-
ination of the stomach and small bowel was made on
January 22, 1946, because of a tendency to vomit occa-
sionally. No evidence of obstruction was found.

Discussion

In the two cases reported there are several factors of
interest. The age of the patients, two months and four
months, is considerably younger than is customary for
mesenteric cysts to cause symptoms.

In one case the baby had had since birth symptoms
indicating partial intestinal obstruction, which became
acute 22 hours before admission. In the other case the
infant had her first symptoms at two months of age,
consisting of vomiting and constipation for one day; she
had acute intestinal obstruction a little less than two
months later, with poor weight gain in the interim. In
one case it was possible to palpate a cystic abdominal
mass; X-ray studies showed a gasless shadow in the right
abdomen, with displacement of intestines to the left.
In the other case no abdominal mass was palpated, and
X-ray films did not show any displacement of the
intestines.

Although mesenteric cysts are usually single, they
were multiple in both of our cases. In both cases resec-
tion and anastomosis were necessary; in one case the gut
was gangrenous, and in the other the cysts were adherent
to the gut. In both cases the cysts were chylous, in spite
of the fact that in one case the cysts arose from the
mesentery of the upper ileum and not the jejunum.

It should be pointed out that both patients were in
poor general condition prior to surgery. Generous ad-
ministration of intravenous and subcutaneous fluids and
transfusions of citrated blood and plasma were an essen-
tial part of treatment. It was felt that a continuous
intravenous drip kept in place for 4J4 days was a life-
saving measure in one case.

Summary

Two cases are reported of chylous mesenteric cysts
causing acute intestinal obstruction in early infancy.
Both infants responded favorably to general and sur-
gical measures.

References

1. Warfield, J. O., J.: A Study of Mesenteric Cysts with a
Report of Two Recent Cases. Ann. Surg., 96:329 (Sept.), 1932.

2. Loeb, M. J.: Mesenteric Cysts: Review of Literature,

Genesis, and Classification. Report of a Case. New York State
J. Med', 41:1564 (Aug. 1), 1941.

3. Ladd, W. E., and Gross, R. E.: Abdominal Surgery of
Infancy and Childhood. Philadelphia: W. B. Saunders Com-
pany, 1941.

May, 1946

155

Mesenteric Cyst

Report of a Case

Ralph E. Dyson, M.D.
Minot, North Dakota

The 18-month old male infant whose case is here
reported was first seen at the Northwest Clinic on
August 7, 1945.

The history obtained from the mother was as follows:
When the infant was one month old a right inguinal
hernia was discovered. An unsuccessful attempt was
made to reduce it and hold it with a truss. From the
age of one year, the parents observed, the child had a
very prominent abdomen.

On July 12, 1945, the right inguinal hernia was re-
paired surgically by the local doctor. When the hernia
sac was opened several small basins of clear, straw-colored
fluid were removed from the abdomen. Following the
surgical procedure the abdomen seemed to enlarge more
rapidly and became very tense. The patient had no vom-
iting, diarrhea, constipation, or urinary symptoms, and
apparently no abdominal pain. He seemed to have some
dyspnea and was uncomfortable when on his back and
much preferred lying on his abdomen. The doctor was
again consulted on August 7, when he made a diagnosis
of ascites and referred the baby to the clinic for further
study and treatment.

At the time of the initial examination at the clinic the
infant’s temperature was 99.2° rectally, the pulse 80,
respirations 20, and weight 25 pounds, 14 ounces. The
results of the examination were negative except for the
abdomen, which was greatly enlarged.

On examination a mass was felt extending from the
right costal arch downward to about two inches below
the navel and about two inches to the left of the mid-
line. The mass was firm, smooth, and not tender to
palpation. There was no movement of the mass on
palpation or with respirations. The percussion note was
dull over the right flank and the entire mass, but reso-
nant below and to the left of the mass. No shifting
dullness was present, nor could a fluid wave be detected.
The spleen was not palpable. Rectal examination was
negative. The differential diagnosis was: (1) right kid-
ney tumor; (2) retroperitoneal sarcoma; (3) mesenteric
cyst; (4) teratoma.

Laboratory findings on admission to Trinity Hospital
were: hemoglobin, 66 per cent; RBC, 4,080,000; WBC,
12,000; differential blood count: PMN’S, 68 per cent;
lymphocytes, 24 per cent; monocytes, 2 per cent; and
eosinophiles, 6 per cent. The urine was negative.

A flat X-ray film of the abdomen showed a large,
opaque mass in the right side of the abdomen. There
was displacement of the colon and small bowel toward
the left and downward. An intravenous pyelogram
showed both kidney pelves and calices to be well visual-
ized. They appeared normal, as did the position of both
kidneys. The ureters were fairly well visualized and
appeared in normal position.

*From the Northwest Clinic, Minot, North Dakota.

The following day a barium enema was given. There
was some difficulty in getting the barium beyond the
splenic flexure, but finally it advanced as far as the
cecum. An anteroposterior film showed the transverse
and ascending portions of the colon markedly displaced
toward the left and downward. (See Figure 1.) The
lateral film showed the descending colon in normal posi-
tion. The transverse portion of the colon was displaced
anteriorly and toward the left to a marked degree, so
that it coincided with the splenic flexure and descending
colon. The cecum was displaced downward into the
pelvis. (See Figure 2.)

We believed that this preminary study ruled out the
possibility of a kidney or retroperitoneal tumor. The
patient was scheduled for an abdominal exploratory
operation by Dr. A. L. Cameron on August 11. The
preoperative diagnosis was either a mesenteric cyst or a
teratoma.

A small right rectus incision was made. Upon opening
the peritoneal cavity we found a large cyst in the upper
abdomen exposed to view. It was punctured and 900 cc.
of clear, straw-colored fluid were removed by suction.
Approximately 200 cc. of fluid escaped around the suc-
tion tube. Most of the cyst was then removed. It arose
from the transverse mesocolon and projected anteriorly
between the stomach and transverse colon, displacing the
colon downward. The lower margin of the cyst was ex-
tensively attached to the transverse colon. The upper
margin was attached to the greater curvature of the
stomach and to the lower edge of the right lobe of the
liver. All but a small remnant of the sac attached to
the transverse mesocolon was removed.

Microscopic examination showed the cyst wall to con-
sist entirely of dense, fibrous scar. No epithelial lining
was demonstrated.

The patient had a smooth convalescent course. On
the fourth postoperative day the hemoglobin was found
to be 50 per cent and the red blood count 2,720,000.
Because of this marked secondary anemia 300 cc. of
citrated blood were given intravenously. The hemoglobin
then rose to 96 per cent and the red blood count to
5,200,000. The infant was discharged on August 22,
the 12th day after surgery.

Discussion

The following discussion is taken chiefly from the
excellent chapter on "Omental Cysts and Mesenteric
Cysts,” by Ladd and Gross, in their book Abdominal
Surgery of Infancy and Childhood.

Etiology. Mesenteric cysts may arise by obstruction of
a lymphatic channel, but the absence of any demonstra-
ble inflammatory or fibrosing lesion in the mesentery
makes this theory improbable. A much more likely
theory is that mesenteric cysts develop from congenitally
misplaced bits of lymphatic tissue, which proliferate and

156

The Journal Lancet

Fig. 1. A.P. film of the abdomen after barium enema, show-
ing the ascending and transverse portions of the colon displaced
to the left by a mesenteric cyst.

then accumulate fluid because there is no communication
with the normal lymphatic channels.

Pathology. The most common site of these cysts is
the mesentery of the jejunum or ileum, but occasionally
they arise from the transverse mesocolon, as in our case,
or in the mesosigmoid.

The cysts lie between the leaves of the mesentery and
are situated anywhere from its base out to the enteric
border. They are commonly of dumbbell shape, owing
to projection from either surface of the mesentery, and
sometimes partially surround the intestine in the form
of a saddle. Such a saddle-shaped cyst may cause stran-
gulation of the adjacent loop of intestine and obstruct it.
The walls of the cysts are thin, and are rarely more than
2 mm. in thickness. Microscopic examination shows the
cyst walls to consist of connective tissue. There is no
muscular coat or mucosal lining. In some specimens a
single layer of flattened endothelial cells can be seen on
the inner surface.

The fluid content of the cysts may be of clear, color-
less serous type or of milky or chylous type. Of eight
cases reported by Ladd and Gross five had a serous and
three a chylous fluid. The chylous cysts arose from the
mesentery of the jejunum. Cysts arising from the mesen-
tery of the large bowel, as in our case, usually contain
serous fluid.

Symptoms and Clinical Findings. The symptoms may
be grouped into three types. (1) Gradual enlargement
of the abdomen, which is painless. This enlargement

Fig. 2. Lateral film of the abdomen after barium enema,
showing the ascending colon displaced anteriorly by a mesen-
teric cyst.

may progress slowly for six months to a year or more
before a doctor is consulted. (2) There may be recur-
ring attacks of abdominal pain, at times associated with
vomiting, anorexia, and poor gain in weight. (3) Occa-
sionally the patient presents the picture of acute intes-
tinal obstruction.

The physical findings, such as palpation o-f the cyst,
depend upon tenseness and the size of the cyst. In most
cases a fairly well-defined mass can be palpated. It is
possible to shift the mass within the abdomen. It is
more freely movable in the lateral direction than in the
vertical. If the cyst is large a fluid wave may be
detected.

Roentgenologic Findings. Films of the abdomen, with
or without barium, often give valuable information, as
the cyst will form a gasless shadow that displaces the
intestine. Under fluoroscopic control the mobility of
the mass can be demonstrated.

Treatment. The surgical treatment of mesenteric cysts
may be handled in one of three ways, depending upon
the conditions. (1) If there is an intestinal obstruction,
with gangrenous bowel due to a saddle-shaped or dumb-
bell type of cyst, the procedure of choice is to excise the
cyst and gangrenous bowel, following with a side-to-side
anastomosis. (2) The cyst may be marsupialized, but
few recommend this type of treatment. (3) The pre-
ferred surgical procedure, unless contraindicated by some
complication, is to dissect the cyst from the mesentery.
If this dissection is carefully carried out the blood supply
to the adjacent gut will not be impaired.

C-i
<- i.

May, 1946

157

Treatment of Chronic Influenzal Meningitis:
Heparin as an Adjuvant

E. S. Platou, M.D., R. W. Gibbs, M.D.,
and Forrest H. Adams, M.D.

Minneapolis

Meningitis due to Hemophilus influenza bacillus
had until recently a case fatality rate close to 100
per cent, especially in children under two years of age.
Today, owing to the work of Dr. Hattie E. Alexander
and others, the disease can be controlled. In 1941
Alexander1 pointed out that owing to advances in chemo-
therapy the immunological therapy, that is, the use of
specific antibody, was being neglected.

"The amount of free specific carbohydrate from the
Hemophilus influenza bacillus present in the spinal fluid
is an index to the severity of the infection, according to
Alexander,1 who also tells how much antibody is neces-
sary. It was found that the spinal fluid sugar level cor-
related well with the severity of the infection; it was also
found that the strength of antibody could be determined
in milligrams of nitrogen. A correlation between the
spinal fluid sugar levels and the amount of antibody
required was then evolved, as shown in Table 1.

Table 1

Amount of Antibody Required for Various Levels
of Spinal Fluid Sugar

Spinal fluid

Antibody nitrogen

sugar

indicated

(mg. per cent) (mg.)

Less than 15 100

15-25

25-40

Over 40 .. .....

It was found that rabbit serum was superior to horse
serum as a medium for antibody, owing, it is believed,
to the smaller molecular size of the protein in rabbit
serum. This smaller molecular size facilitates penetration
of body tissues.

A method of determining antibody adequacy was *
found by checking the capsular swelling of the Hem- .
ophilus influenza bacillus with the patient’s serum. If *
there is swelling with a 1-10 dilution of the patient’s
serum, a surplus of antibody is considered to be present.
This check is made one hour after antibody is injected.

Sulfadiazine has come to replace all other sulfona-
mides, with the exception of sulfamerizine, in treating X
influenzal meningitis. The best results are obtained when ^
a level of 20 mg. per cent is attained in the blood. 3
Penicillin has been shown to be of no value. Strep- g
tomycin seems to be a specific antibiotic.

Even with these methods of treatment, early diag-
nosis is a big factor in recovery. The method employed
is the finding of gram-negative rods or pleomorphic

diplococci on direct smear and capsular swelling, when
the organisms are mixed with type-specific rabbit anti-
sera, typ>e B. Confirmation is made by culturing the
organisms in Levinthal broth. "The advanced stage of
the disease and the presence of irreparable damage at
the time therapy was started was responsible for the high
death rate,” according to Alexander.2

Early diagnosis is not always easy. "The patient’s
failure to manifest clear-cut signs of meningeal irrita-
tion until several days after onset when under seven
months of age makes the diagnosis difficult.” 2 We have
found that in any of the various types of meningitis
children under one year of age often have no signs of
meningeal irritation until late in the disease. Unex-
plained fever, bulging fontanel, and irritability are symp-
toms sufficient to warrant a spinal puncture.

Chronic influenzal meningitis still carries a high case
fatality, especially in the very young. Alexander3 uses
the term "chronic” to "designate the clinical status of
the patient rather than the disease.” Those who have
striking rigidity of the extremities as well as the trunk
and show a preference for the opisthotonus position are
considered to be in this group. They may also have
other signs caused by damage to cerebral cells. These
cases are believed to be due to late treatment or long-
standing inadequate treatment.

(PATIENT G. R.)

The authors are grateful to Dr. Irvine McQuarrie for help
in preparing this paper for publication.

Fig. 1. Course of patient G. R.

158

The Journal Lancet

(PATJIHT ]. P.l

Fig. 2. Course of patient J. P. through main part of illness. Note: Hep-
arin and air given via ventricles.

The three cases presented here meet the criteria of
chronic influenzal meningitis. Intrathecal and intraven-
tricular therapy was carried out with antibody. Heparin,
air, and complement injection, as well as specific therapy
as suggested by Alexander, were used. We believe the
successful treatment of these cases to be of sufficient
interest to warrant reporting them.

Case Reports

Case 1. G. R., a two-year-old white male, was admit-
ted on May 9, 1945, to the University of Minnesota
Hospital. The child had become ill four weeks previous
to admission. He had a sudden onset of diarrhea, vom-
iting, fever, muscular twitchings, stiff neck, and head-
ache. His local doctor did a spinal tap, which revealed
12,000 cells. After treatment with one of the sulfas his
spinal fluid was negative in two weeks. After he was
home two days symptoms of diarrhea, vomiting, and
fever recurred. The presence of Hemophilus influenzce
bacilli (type B) was proved by culture. Sulfa was re-
started and 50 mg. of type B anti-Hemophilus rabbit
serum were given subcutaneously. His course continued
downhill up to the time of his admission to the Uni-
versity Hospital.

Physical examination revealed a well-developed, poorly
nourished boy who appeared chronically ill. His position
was opisthotonic. He had a divergent squint and a slight
exophthalmus. The fundi had blurring of the disc mar-
gins, and a 2 to 3 diopter choke was apparent. The
throat was injected. A systolic murmur was heard at
the apex. The reflexes were hyperactive, and there was
an unsustained bilateral ankle clonus. The Brudzinski
and Kernig signs were both positive.

The temperature was 102.8°; the hemoglobin, 8.6
grams; the white count 15,150, with 85 per cent neu-
trophiles and 14 per cent lymphocytes. The urine was
negative. A spinal tap showed a pressure of 34 mm.
of mercury with 550 cells, of which 31 per cent were
neutrophhes and 69 per cent mononuclears. The pro-
tein was 76 mg. per cent and the sugar below 30 mg.
per cent. No organisms were found on the smear or
culture.

The patient received a total of 300 mg. of antibody
over a period of 12 days and enough sulfamerazine to
give a blood level of 19 to 20 mg. per cent. He became
afebrile on June 22, 1945, and improved steadily to the
time of discharge. The sulfa dosage was reduced three
days before discharge.

On July 4, 1945, his progress appeared normal and
he was in good health.

Case 2. J. P., a two-month-old white female, was ad-
mitted March 16, 1945, to the Minneapolis General
Hospital. The child had been ill for 11 days. At the
onset of illness she had the symptoms of a cold. She
had been vomiting for four days and had had a fever
for two days.

Physical examination revealed a well-developed, poorly
nourished white female, who cried easily on being han-
dled. The turgor was poor and the anterior fontanel
was bulging slightly. The throat was inflamed and the
cervical glands were palpable. Flexion of the spine
caused crying. The Brudzinski and Kernig signs were
positive. The rest of the physical examination was essen-
tially negative.

The temperature was 101°; the hemoglobin, 61 per
cent; the white count, 4500, with 19 per cent neutro-

May, 1946

159

IWIWT 1. L.l

Fig. 3. Course of patient J. L.

philes and 75 per cent lymphocytes. The urine was nega-
tive. A spinal tap revealed white purulent material.
There were 1087 cells, of which 84 per cent were neu-
trophiles and 16 per cent monocytes. Pleomorphic gram-
negative rods were seen on the smear, and later culture
showed the presence of type B Hemophilus influenzce
bacilli. An X-ray suggested beginning bronchopneu-
monia.

Penicillin was started and given intrathecally, hut was
stopped after 24 hours when the organism was known.
Sulfadiazine was given in dosage of 3 grains per pound
p>er day, which gave a level of about 12 mg. pier cent in
the blood. A total dosage of 244 mg. of antibody was
given by vein, spinal canal, and ventricles over a period
of 40 days. The child was given 1 cc. of heparin on
the 11th and 12th days because of suspected block. The
child had convulsions and assumed the opisthotonus posi-
tion. No organisms were cultured after the third day.
Spinal fluid was drained off each day and complement
and air totaling 15 cc. were injected. The dosage of anti-
body was determined by the blood sugar and capsular
swelling test.

A complication in her course was an agranulocytosis,
which developed 30 days after admission, while she was
on sulfadiazine. The sulfa was discontinued, and blood
transfusions, crude liver, and iron were given. Her re-
covery was uneventful. Her extended hospital stay was
for treatment of the agranulocytosis and because her
lungs continued to show consolidation. No organism
was cultured from the sputum.

The child was last seen on October 25, 1945. She
appeared well, and her head was within normal limits
in size. The mother thought she was somewhat less
advanced than the other children.

Case 3. J. L., a two-year-old white male, was admit-
ted July 16, 1945, to the University of Minnesota Hos-
pital. He became ill four weeks previous to admission.
The local doctor diagnosed the case as pneumonia and
started the child on penicillin. The child became worse
and was admitted to the local hospital, where his illness
was diagnosed as acute meningitis. Penicillin was contin-
ued, and at the end of 10 days the child was discharged
afebrile and in fair condition. In one week he developed
fever and became irritable. His local doctor did a spinal
tap and meningitis was again diagnosed. He was then
brought to the University Hospital.

Physical examination revealed a chronically ill, poorly
nourished child. There was a bilateral papilledema of
one diopter. The Kernig and Brudzinski signs were posi-
tive. The rest of the physical examination was essen-
tially negative.

The temperature was 101°; the hemoglobin, 11.2
grams; the white count, 25,550, with 68 per cent neu-
trophiles and 28 per cent lymphocytes. The urine was
negative. There were 1000 cells in the spinal fluid, of
which 92 per cent were neutrophiles and 8 per cent
mononuclears. The protein was 76 mg. per cent and the
sugar was below 30 mg. Smears showed gram-negative
pleomorphic rods, which swelled when antibody was
added. The liquid proved on culture to have type B
Hemophilus influenzce bacilli.

The patient received a total of 100 mg. of antibody
on admission. Penicillin was started four days after ad-
mission and given for six days. He received sulfadiazine,
2 grains per pound. His spinal fluid was negative for
bacilli after July 18. He improved rapidly and was dis-
charged August 7, 23 days after admission.

He was readmitted seven days later because of rest-
lessness, stiff neck, fever, and vomiting. The physical

160

The Journal Lancet

examination showed an acutely ill child. His fundi still
showed a one diopter choke. The Brudzinski and Kernig
signs were positive. The rest of the physical examina-
tion was negative.

The temperature was 100.4°; the hemoglobin, 12.5
grams; the white count, 18,200, with 61 per cent neu-
trophiles and 36 per cent lymphocytes. The urine was
negative. The spinal tap revealed 2400 cells, of which
83 per cent were neutrophiles and 17 per cent mono-
nuclears. The sugar was below 30 mg. per cent, and
the protein was 165 mg. per cent. The fluid proved on
culture to have type B Hemophilus influenzce bacilli.

He was put on sulfadiazine, 2 grains per pound, for
29 days. He received 175 mg. of antibody. He was
discharged, completely recovered, on September 21,1945,
39 days after admission.

Discussion

The treatment of chronic meningitis due to Hemoph-
ilus influenzce bacillus is still experimental. The prob-
lems of exudate in the small avenues of communication
of the foramina and the subdural spaces, lack of ade-
quate concentration of antibody in these areas, and in-
sufficiency of bacteriostasis may arise singly or in com-
bination.

Poor drainage, disparity in the character of fluid from
the ventricle and the spine, abnormally high protein

levels, and persistently low sugar levels are suggestive
adjuncts in the presence of clinical signs of rigidity,
tremor, opisthotonus, and positive cultures from the
cerebrospinal fluid.

Intrathecal serum may furnish the desired concentra-
tion, but may also enhance the problem because of local
antibody antigen reaction. Heparin may help liquefy
exudate and air injected later may open the delicate
pathways so that curative media may reach their goal.
Recent studies suggest that streptomycin may comple-
ment or even supplant sulfonamides as a bacteriostatic
agent against Hemophilus influenzce.

Summary

The protocols presented here suggest that cases here-
tofore regarded as hopeless even under modern therapy
deserve the most energetic treatment at our disposal.

Heparin given intrathecally in the acute stages of in-
fantile meningitis is worthy of trial to avert chronicity,
with its potentially serious or fatal sequelae.

References

1. Alexander, Hattie E.: Treatment of Bacterial Meningitis.
New York Acad. Med., 17, 100 (Feb.), 1941.

2. Alexander, Hattie E., Ellis, Catherine, and Leidy, Grace:
Treatment of Type-Specific Haemophilus Influenzae Infections
in Infancy and Childhood. J. Pediat., 20, 673 (June), 1942.

3. Alexander, Hattie E.: Treatment of Type B Haemophilus
Influenza Meningitis. J. Pediat., 25, 517 (Dec.), 1944.

ANNUAL MEETING, SOUTH DAKOTA STATE MEDICAL
ASSOCIATION, ABERDEEN, JUNE 1-4

The program for the 1946 annual meeting of the
South Dakota State Medical Association is virtually
complete. Among the speakers, each outstanding in his
field are:

Alton Ochsner, M.D., Surgeon, Tulane University
Medical School, New Orleans; H. H. Bowing, M.D.,
Radiologist, Mayo Clinic, Rochester; J. R. McDonald,
M.D., Pathologist, Mayo Clinic, Rochester; W. A.
Oughterson, M.D., Medical Director, American Cancer
Society, New York. (On Tuesday afternoon, June 4th,
a symposium on cancer will be conducted, with these four
distinguished speakers participating.)

A. B. Price, M.D., District Surgeon, U. S. Public
Health Service, Kansas City.

A. W. Adson, M.D., Rochester, Member of the Coun-
cil on Medical Service and Public Relations, A.M.A.

N. C. Gilbert, M.D., Internist, Northwestern Univer-
sity Medical School, Chicago.

T. P. Grauer, M.D., Urologist, Northwestern Uni-
versity Medical School, Chicago.

Walter C. Camp, M.D., Ophthalmologist, University
of Minnesota Medical School, Minneapolis.

J. Harry Murphy, M.D., Pediatrician, Creighton
University Medical School, Omaha.

Leonard A. Lang, M.D., Obstetrician-Gynecologist,
University of Minnesota Medical School, Minneapolis.

Gordon R. Kamman, M.D., Psychiatrist, University
of Minnesota Medical School, St. Paul.

Earl C. Elkins, M.D., Physiotherapist, Mayo Clinic,
Rochester.

Kenneth G. Kohlstaedt, M.D., Internist, Indianapolis.

Wendell Hall, M.D., Internist, University of Minne-
sota Medical School, Minneapolis.

Kenneth A. Phelps, M.D., Otolaryngologist, Univer-
sity of Minnesota Medical School, Minneapolis.

Additional features of the meeting will be a banquet,
a stag party, and a golf program.

Members are urged to communicate with hotel res-
ervation chairman Dr. J. A. Eckrich, Aberdeen, South
Dakota, regarding hotel accommodations.

May, 1946

161

Direct Psychiatric Treatment of the Child

Hyman S. Lippman, M.D.

St. Paul

By direct psychiatric treatment is meant the therapy
that takes place in interviews between psychiatrist
and child. Treatment of the child alone, without work
with the parents, is uncommon. Limitation of this dis-
cussion to what happens in direct treatment alone is not
in any way intended to detract from the importance of
indirect treatment with the parents, school, and neighbor-
hood which so vitally affect the child’s life.

Psychiatric treatment work with the child will not be
effective unless the child wants help and sees the need
for it. In the neurotic child anxiety, so important a part
of neurosis, will help to motivate him. It is therefore
unwise to reassure the child early or use suggestion treat-
ment that will eliminate anxiety. Through so doing one
may lose a great ally in the treatment process. The
neurotic child soon becomes aware that the therapist will
help him master the anxiety. He, as well as the therapist,
must appreciate that until the causes for anxiety can be
located and eliminated, he will continue to suffer.

In treating delinquent children one does not have the
aid of the factor of anxiety, and for that reason it is
often difficult to keep a delinquent child in treatment.
In the case of the delinquent child it is not the child
who is anxious; instead, it is the parents or the com-
munity or the school.

There is a large group of delinquent children whose
delinquencies result from emotional conflict. They are
called neurotic delinquents. In many instances they
suffer a great deal from anxiety, and to this extent they
are amenable to treatment. Particularly is this true when
a child has the feeling that his delinquency has gotten
the best of him and that he has little control over his
behavior.

Most of the good results from the direct treatment
of a delinquent child come through the child’s identifi-
cation with the therapist. It is surprising in how many
cases the delinquent child who comes in for psychiatric
treatment has never previously developed a warm affec-
tionate tie with any adult. If the therapist is patient, can
overlook recurrences of delinquency during the period of
treatment, and can retain his affection and respect for
the child, the child may respond by finding it difficult
to continue to be delinquent through a fear of hurting
or displeasing the therapist.

There is a large group of children who suffer from
defects of character. They have developed defense mech-
anisms as a result of which they become unpopular and
unhappy. Most of these defense mechanisms are a
cover for deeper anxiety, which may come to the surface
through a series of interviews. These children are not
willing to submit to treatment unless they are strongly
urged to do so by their parents. It is of the utmost

From the Amherst H. Wilder Child Guidance Clinic, St.
Paul, Minnesota.

importance, therefore, that the parents should not only
be interested in treatment for their child, but also that
they should sustain this interest. In this group of chil-
dren with character defects are the bully, the chronic
complainer, the egotist, the child who projects responsi-
bility for his behavior onto others, the child with feelings
of inferiority, and so forth.

The child psychiatrist able to deal directly with diffi-
cult children must know children well, especially their
habits, interests, weaknesses, needs, and fears. He must
understand that most children, and especially difficult
ones, have definite prejudices against adults, whom they
distrust and of whom they are suspicious. Most of their
suffering and their need to develop defense mechanisms
has come from stupidities, cruelties, neglect, and rejec-
tion from adults.

The child psychiatrist must be fond of children. If
he is not, the child will recognize it quickly, and the
child’s distrust will be the greater. He must be sincere
with them. Children recognize very quickly who is their
friend and who is not. He must be able to recognize
when he is not wanted or needed in a treatment pro-
gram, so that he can withdraw from a treatment that
is useless. He must not be disillusioned with the child,
and it is important that the child should not at any time
feel that the therapist believes his case to be hopeless.

He must be able to recognize the various forms that
anxiety takes. It is not difficult to recognize the suffer-
ing of a child who has fears, phobias, or nightmares.
It is often difficult to recognize that under the need to
fight may be an anxiety of being overwhelmed; that
under a severe anorexia may be a fear of being poi-
soned; that under a lack of interest in aggressive sports
may be a fear of being hurt. It is only through know-
ing children intimately that the therapist learns to spot
the large number of distorted forms anxiety can take.

One of the major contributions of psychoanalytic
research is the recognition of the tremendous role that
anxiety plays in the lives of individuals — by factors of
an unconscious nature that are not apparent either to
the individual who suffers or to the therapist. A knowl-
edge of the psychology of the unconscious is indispens-
able to the therapist dealing with the problems of chil-
dren. Not that the therapist must be an analyst; but he
must know what unconscious factors are and how they
affect behavior.

There are several methods of learning about the child’s
anxieties. Often this knowledge can be obtained through
a history given by the mother, the teacher, or someone
else who has had contact with the child. Anxieties can
be recognized through various forms of play techniques,
in which the child is subjected to play material and one
can note avoidances, attacks, and reactions of fear to
what he creates in the play or to suggestions made by
the therapist that will help to bring out reactions. Some-

162

The Journal Lancet

times the child’s drawings will reveal anxiety. In the
direct interview one can ask frankly about fears, indicat-
ing through questions that all children have fears. The
child may speak frankly about his fears, or he may deny
them overemphatically. His statements should not be
contradicted, though they may be treated lightly — as
though the child were trying to fool or joke with the
therapist. The extent to which this procedure can be
followed safely will vary with different children.

The use of dream material has been generally over-
looked because it has been used largely by the analyst,
who is trying to get at unconscious conflicts. If the
therapist can get the child to talk about his dreams he
may be rewarded with an abundance of significant ma-
terial. The dreams may contain references of hostility
toward a brother, sister, or parent; concern regarding
school; fear of older boys; fear of sexual assault; fear
of insanity; and preoccupation with sex.

Having told his dreams the child may, in response to
suggestions from the therapist, go on discussing the sub-
jects present in the dream — subjects that may never have
come to light in the ordinary interview. It is interesting
how often a child is willing to discuss fears that ap-
peared in dreams when he would have been reluctant
to discuss them otherwise. Children often deny that they
dream, but when told that all children dream, or when
asked specifically "What is the funniest or scariest dream
you ever had?”, they may start out by telling a dream
and then telling many others.

There is little danger from using dreams in such a
way to help in the recognition of current problems.
Danger arises only when the therapist unwittingly makes
interpretations of unconscious material that he may rec-
ognize in the dream. Interpretation of unconscious con-
tent is not the work of the child psychiatrist; it is the
work of the child analyst.

Direct treatment work with young children of both
sexes is often more successfully carried out by women
therapists. The young child is closer to his mother,
whom he identifies with a woman therapist, and has
more confidence in her. Women have much greater
patience in play techniques with younger children.

The child psychiatrist must be well acquainted with
the problems of children in foster homes. He must un-
derstand the relation of the child to the foster home
and to the child’s own family, from whom he has been
removed. He must know the many conflicts that arise
in the relation between parents and foster parents and
between both groups and the placement agency. He
must also be aware of the problems that arise when a
child is placed in an institution. He must have an un-
derstanding of educational problems as they are related
to the school, the teacher, and the principal. He must
be aware of the conflicts related to school failure. He
must have a clear picture of the relationship between
parents and children and between individual children
and other members of their family.

At all times the child’s right to withhold information
must be respected. The forcing of material may increase
rather than lessen suffering, especially in relation to
anxieties. The ability to recognize when a child is being
helped rather than threatened comes only from years
of experience in treatment work with children. If treat-
ment is not successful it should be discontinued and
tried again later on.

Obviously there have been many omissions in this
brief discussion of direct treatment work with children.
The reader is referred to the rich literature on the sub-
ject in such periodicals as The American Journal of
Orthopsychiatry, Mental Hygiene, Psychiatry, and The
Psychoanalytic Quarterly. Important books on the sub-
ject have been published recently and are referred to
in these periodicals.

AMERICAN RED CROSS APPOINTS NEW MEDICAL DIRECTOR

Dr. Courtney M. Smith has been appointed the new medical director of the American
Red Cross, according to an announcement of the national headquarters. He succeeds G.
Foard McGinnes, recently appointed vice chairman for health services.

Dr. Smith has served with the organization since 1944 as deputy medical director and
director of disaster medical service. A graduate of the University of Oregon Medical School
and Yale University, he entered public health work in Clackamas County and Portland,
Oregon, after three years of private practice in Oregon City and Portland. He was then
appointed health officer for the Territorial Department of Health in Alaska, with headquar-
ters in Juneau. From April 1946 until his Red Cross appointment he was a medical officer
in the Office of Civilian Defense.

May, 1946

163

Giant>Cell Tumor of Bone in a Four-Month-Old Infant

William E. Proffitt, M.D., and Oswald S. Wyatt, M.D.

Minneapolis

In 1892, while Dr. J. C. Bloodgood was working with
Halsted on an excision of a so-called giant-cell sar-
coma, Halsted called attention to the fact that Koenig
in his System of Surgery had reported two cases of this
type that had been cured by curettage and chemical
cautery.

Bloodgood then began correspondence with the per-
sons represented by the cases of sarcoma on record at
Johns Hopkins Hospital. He noted one surprising fact:
that all persons who had been diagnosed as suffering
from giant-cell sarcoma answered him in a cheerful vein,
but from those with other sarcomata he received no an-
swer, because they were usually dead or dying. Blood-
good’s memorable work,1 published in 1910, reported his
findings and a summary of 22 cases of giant-cell tumor
of bone. From time to time he added more cases and
reviewed his previous cases in the light of new observa-
tions.2,3

In this paper we shall attempt a review of the litera-
ture of giant-cell sarcoma to date, add a case in a very
young infant, and attempt to draw some conclusions
about this very confusing subject.

Review of Literature

Giant-cell tumors of bone are, by definition, very low-
grade neoplastic processes, usually single, affecting main-
ly the epiphyses of the long bones, and running a pro-
gressive, prolonged course, but not metastasizing. Their
microscopic pathology is a more or less vascular network
of spindle-shaped or ovoid stromal cells and multinuclear
giant cells.

These tumors were first recognized by Ambroise Pare
when he described benign tumors of the maxilla cured
by curettage or repeated excision. Beclard (1827), War-
ren (1837), and Robin (1850) all described benign
medullary tumors of bones with giant cells. Our first
modern report of this condition was published by Nela-
ton (1863), who insisted that these tumors were benign.
Nevertheless, until the publication of Bloodgood’s re-
ports the consensus of medical opinion and practice
regarded these tumors as malignant and as belonging
to the sarcoma group. Bloodgood insisted, and proved,
that they were relatively benign, that the treatment be-
ing used was too radical, and that the name should be
changed from "giant-cell sarcoma” to "giant-cell tumor
of bone.”

The etiology of these tumors is unknown. By some
men trauma is thought to play a part. Others believe
that such tumors represent an exaggeration of the nor-
mal process of ossification and bone growth, with resorp-
tion of calcified cartilage by new blood vessels and giant
cells. Still others believe the process to be definitely
malignant. It is a confusing array of data and evidence
with which we are confronted, and the last words are
yet to be said.

Giant-cell tumors occur equally in males and females
and occur most frequently from 25 to 35 years of age.
However, Davis '1 in Philadelphia (1903) reported one
case in a 2 !4 -year-old girl, and one case in a male aged
61 has been reported. The lower end of the radius, the
upper end of the tibia, and the lower end of the femur
are by far the most common sites of occurrence in the
cases reported. None have been reported in the humerus
or ribs. When a painless swelling, of a bone occurs which,
on X-ray, shows an asymmetrical swelling, usually at the
epiphysis, with characteristic trabeculation, we should
think of giant-cell tumor. However, the diagnosis is not
conclusive until a biopsy and microscopic study can be
made.

In the days before Bloodgood there was much better
gross material to study, because of the treatment of
giant-cell tumor by block excision, and so our present-
day concept of the gross pathology of these lesions dates
from the work of Paget, Nelaton, and Gross. There is
a distended area in the epiphyseal end of the bone, with
a thin shell of bone covered with a thickened periosteum.
This thin bone shell is new bone that has replaced the
old cortex, which was resorbed. All the substantia spon-
giosa is usually resorbed also. This lesion often invades
the joint cartilage, but is almost always separated from
the narrow cavity by a thin fibrous layer. In the late
stages these tumors undergo necrosis, cystic degeneration,
hemorrhage, and the formation of blood spaces.

There are thought to be four distinct types grossly,
namely: (1) a solid tumor filling a bony shell; (2) a
tumor filled with large and small cavities, containing
blood and resembling a cavernous hemangioma; (3) a
tumor resembling a hemorrhagic bone cyst; and (4)
a tumor that perforates the bony shell and invades the
soft tissues.

The microscopic pathology is that of stromal cells,
which are vascularized and multinucleated giant cells
with a few collagenous fibrils interspersed (Figure 1).
These stromal cells are mononuclear, spindle shaped or
ovoid, and resemble young connective tissue cells (fibro-
blasts) . The nuclei are long and narrow and have a
central nucleolus; there are few if any mitotic figures.
The giant cells are multinuclear and usually 30-60 mi-
crons in diameter, but may be 100 microns or more.

The origin of these giant cells is questionable, but they
are thought to be megakaryocytes, or osteoclasts, or col-
lections of stromal cells by fusion, or puffed-up endo-
thelial cells of the lining of the blood vessels.

Jaffe thinks that Bloodgood’s claims for the benignity
of these tumors are definitely false. He grades them into
three classes on the basis of the activity of the stromal
cells in the worst area of the tumor. Grade I is rela-
tively benign, with uniform-sized stromal cells and rare
mitotic figures. Grade II is of increasing malignancy
or less benign appearance because of atypical stromal

164

The Journal Lancet

Fig. 1. Photomicrograph of giant-cell tumor of bone. (X170.)

cells, with great differences in size and shape, but still
very few mitotic figures. Jaffe’s grade III is frankly ma-
lignant. He states that this group is rare and has abun-
dant, closely packed stromal cells with much whorling.
Also, the nuclei are large and varied in both shape and
location in the cell. The giant cells are small and
squeezed together.

Treatment, Prognosis, and Differential
Diagnosis

In spite of all the facts I have reviewed, the treatment
still remains as Bloodgood outlined it: first, the lesion
is curetted and chemical cautery is applied to the base.
Then if the tumor recurs locally an excision or a local
resection is done, with a bone graft to fill the defect.
Radiation is used in conjunction with these procedures.
As a last resort, if the tumor recurs we may have to
amputate to save deformity and dysfunction.

The prognosis as to life is excellent, and many factors
can influence the character and appearance of these
lesions without changing their benign character. Many
efforts have been made to prove that they metastasize,
but Stone and Ewing ■'* reviewed all alleged cases of
metastasis up to 1922 and found none in which the
metastasis showed the structure of giant-cell tumor of
bone. Since 1922 Ewing has checked several new sus-
pected cases with the same results. However, in 1926
Finch and Gleave 8 reported a case of a man, aged 49,
who ten years after he first experienced symptoms in
his knee, had a giant-cell tumor removed from the knee,
and five years later died from pulmonary metastasis that
microscopically appeared identical to his original giant-
cell tumor.

The differential diagnosis includes osteolytic sarcoma,
chondrosarcoma, metastatic carcinoma to bone, benign
bone cyst, hemorrhagic bone cyst, multiple myeloma,
xanthomatosis (especially Schiiller-Christian’s disease) ,
fibrosarcoma, and osteitis fibrosa cystica.

In brief, giant-cell tumors are benign in nature; the
general treatment has until recently been too radical; and

the only absolute diagnostic criterion is biopsy and micro-
scopic study of the paraffin sections.

Report of a Case

Our case is that of a four-month-old white male in-
fant, referred to us by Dr. E. F. Robb. The delivery
of the child was uneventful and the baby had had pedi-
atric care since birth. He was breast fed and was also
given homicebrin and 50 mg. of vitamin C daily. He
had an eczematoid eruption on cheeks and neck which
responded to crude coal tar ointments.

When he was three months of age the mother noted
a swelling in his left leg just below the knee. It was
present for a short time but disappeared with application
of heat. The swelling reappeared at about 3J4 months
of age, when we first saw the infant.

Fig. 2. X-ray of the left tibia of a four-month-old
infant, showing osteolytic lesion.

The X-ray (Figure 2) showed an osteolytic lesion in
the upper end of the left tibia; it appeared to be ma-
lignant. We explored this lesion and removed it by curet-
tage and chemical cautery. We believed it to be a bone
cyst or a giant-cell tumor. The leg was immobilized with
a plaster cast. The pathological diagnosis was returned
as giant-cell tumor of bone, benign. This diagnosis has
been substantiated independently by three pathologists.

The child showed steady improvement until he was
about six months of age, when he developed a severe
diarrhea and almost expired. He is now over this illness
and appears to be doing nicely. The site of the tumor
is filling in with new bone.

Bibliography

1. Bloodgood, J. C: Ann. Surg., 52, 145, 1910.

2. Bloodgood, J. C.: Ann. Surg., 56, 210, 1912.

3. Bloodgood, J. C.: Ann. Surg., 69, 345, 1919.

4. Coley, W. B.: Am. J. Surg., 28, 768, 1935.

5. Davis, G. G.: U. Penn. Bull., 18, 249 (Nov.), 1905.

6. Dyke, S. C.: J. Path. & Bact., 34, 259, 1931.

7. Ewing, James: Neoplastic Diseases. 4th ed. rev., 1942.

8. Finch, E. F., and Gleave, H. H.: J. Path. & Bact., 29,
399, 1926.

9. Geschickter, C. F., and Copeland, M. M.: Arch. Surg.,
19, 169, 1929.

10. Geschickter, C. F.: J. Bone & Joint Surg., 17, 3, 550
(July), 1935.

11. Geschickter, C. F.: Am. J. Roentgenol., 34, 1 (July),

1935.

12. Geschickter, C. F.: Bone Tumors. Boston: Christopher,

1936.

13. Geschickter, C. F.: Surg. Clinics North America, Oc-
tober, 1936.

May, 1946

165

14 Gross, S. W.: Am. J. M. Sc., 78, 17, 1879.

15. Jaffe, H. L.: Arch. Path., 30, 933, 1940.

16. Jaffe, H. L.: Bull. New York Acad. Med., 16, 291,
1940.

17. Jenckel: Deut. Zeitsch. f. Chir., 64, 66, 1902.

18. King, E. S. J.: Brit. J. Surg., 20, 269, 1932.

19. Koenig: System of Surgery, 1894.

20. Kramer: Arch. f. Klin. Chir., 66, 792, 1902.

21. Morton: Brit. M. J., July 23, 1898.

22. Orr, J. W.: J. Path. & Bact., 34, 265, 1931.

23. Stewart, F. W., Coley, B. L., and Farrow, J. H.: Am.
J. Path., 14, 515, 1938.

24. Stewart, M. J.: Report, International Conference on

Cancer, p. 381. London: 1928.

25. Stone, W. S., and Ewing, J.: Arch. Surg., 7, 280, 1923.

26. Virchow and Rindfleisch: History of Pathology, 1872.

Boole Reviews

Skin Diseases in Children, by George M. Mackee, M.D.,

and Anthony C. Cipollaro, M.D. New York: Paul B.

Hoeber, Inc., 1946. Pp. 448, illustrated, $7.50.

Skin diseases in children occur frequently enough to give
every practitioner a chance to treat them. Many of these con-
ditions require an early diagnosis and treatment in order to
save the child unnecessary suffering and the parents much dis-
pleasure. If the cutaneous diseases are recognized early and
properly treated the response is usually satisfactory, for in the
child there is a great tendency for healing to take place.

The authors of this book have done a good job of presenting
practical points in the handling of skin diseases in children by
simple classifications, good grouping, valuable brief descrip-
tions, and discussions of the most essential features of therapy.
The book has been well received in the past and will be more
valuable in the future.

The eminent co-authors devote special sections to tubercular,
eczematous and erythematous infections, diseases of the mouth,
hair, and glands, and diseases due to physical agents, parasites,
fungi, and pyogenic bacteria. There are also excellent contrib-
uted chapters: by Frances Pascher on allergic dermatoses,

Eugene Traub on congenital anomalies, Nathan Sobel on con-
tagious diseases, and Herman Beerman on syphilitic infections.
— A.V.S.

Intravenous Anesthesia, by R. Charles Adams, M.D., C.M.,

M.S. (Anes.), Mayo Clinic, Rochester, Minnesota. New

York: Paul B. Hoeber, Inc., 1944. Pp. 663, illustrated. $12.

This volume came from the presses during the war. The
author sensed significantly this handicap. Material that would
have been included was unavailable in a completed form suit-
able for textbook use. Paper shortages, with fewer pages in the
regular journals; travel restrictions, with fewer opportunities to
present work; and the restricted nature of investigations, which
left many manuscripts in laboratory files — all made the collec-
tion of material a mighty task.

The author did the job well. The conviction is clear that
Dr. Adams intended to accumulate all the useful and interest-
ing knowledge of the subject in the one volume devoted to it.
In the present state of knowledge of anesthesia it is likely that
books on the subject will follow this idea, rather than make
attempts to put the entire subject between two covers.

Intravenous Anesthesia may serve as a model for similar
volumes. With its beginning on historical considerations, it
continues to techniques, and then treats separately the various
new and old drugs given by vein for anesthesia. Of the more
than 600 pages, 450 are correctly devoted to the barbiturates,
and nearly 100 pages to pentothal sodium. An amazing feature
of the book is the bibliography distributed to each chapter.
More than 3000 references in all are used, not only for com-
pleteness but also for their bearing on the subject matter.

The author writes plainly but interestingly, and has drawn
on his own wide experience in this field as well as that of his
confreres at the Mayo Clinic for much of the material. The
book is attractively published, with good illustrations, an easily
readable type, and durable paper.

The book will serve the anesthesiologist well and will become
a reference volume for anyone interested in the subject. It is
complete to date of publication. — E.A.R.

The Physiology of the Newborn Infant, by Clement A.
Smith, M.D. Springfield, Illinois: Charles C Thomas,

1945. Pp. 312, illustrated, $5.50.

With the modern tendency to give the mother plenty of
attention, the newly born infant is often permitted just to
"get along.” Fortunately, progress is usually good, but symp-
toms and signs indicating abnormal ponditions do appear occa-
sionally. In the past these conditions have been diagnosed and
treated in a more or less traditional fashion, and no great
effort has been made to investigate the underlying truths for
the various forms of therapy.

Dr. Smith, who has a genuine interest in the newborn child,
presents in his book a comprehensive review of the background
for up-to-date care of the newborn infant. There are chapters
on respiration, the circulatory system, the blood of the infant,
metabolism and heat regulation, the digestive tract, fetal and
neonatal nutrition, and other important features of the new-
born period of life. The reader of the book cannot help but
feel that he has received in a well-organized way a thorough
basis for the better handling of the newborn child, whether it
be routine care or the treatment of an abnormal condition or
disease. For this reason the book is highly recommended to
the student of medicine and the practitioner. — A.V.S.

Science and Scientists in the Netherlands Indies, edited by
Pieter Honig and Frans Verdoorn. New York: G. E.
Stechert and Board for the Netherlands Indies, 1945. Pp.
491, illustrated. $4.00.

This meaty volume is a collection of some eighty items deal-
ing with the sciences, past and present, in the Netherlands East
Indies. Some are here published for the first time, others are
reprinted. Of the group of eighty, five deal with medical re-
search and education, two with veterinary science, and a short
series with cinchona. Others concern varied aspects of astron-
omy, climatology, geology, botany, zoology, and education and
scientific organizations, wherein the UNRRA already finds
place. Within the fields of this reviewer’s knowledge there could
scarcely have been a better choice of authors. The list of insti-
tutions and scientific workers in the Indies, found in a sup-
plement, is likely to be as useful as any part of the volume
if political stability soon returns to the area.

Dr. I. Snapper of Mount Sinai Hospital, New York, in an
article entitled "Medical Contributions from the Netherlands
Indies,” observes that despite the relatively small number of
physicians working in the enormous area of the Indies (760,000
square miles, 3000 islands over a 3000-mile arc, 65,000,000
people) , health was on a high standard for such an unhealthy
climate. The death rate, 20 to 25 per thousand, is considered
good for an Oriental population. Smallpox and cholera are
said to be practically eradicated and plague well under control.
The reader is impressed with the importance of the medical
problems here facing Dutch and Indonesian medical men, for
Java has the world’s densest population (16,000 per square mile
in central Java) and other parts of the Netherlands Indies have
some of the world’s worst jungle.

The text is in small type, but since the book is not likely
to be used except for reference this is no fault. The binding is
attractive and adequately substantial for a book having the
weight of this volume. The coarse screening of many of the
halftones prevents the book’s being considered a good candidate
for a position among the "best produced volumes of the year,”
as the publishers have wished in an accompanying advertise-
ment.— R T. Hatt, Director, Cranbrook Institute of Science.

166

The Journal Lancet

Two Cases of Hemolytic Anemia with Leukemoid
Reaction of the Myeloid Type

S. L. Arey, M.D.

Minneapolis

A leukemoid reaction is one in which the peripheral
blood stream gives evidence of leukemia which is
not substantiated by either the subsequent course or by
necropsy findings. These reactions may occur in many
varied conditions and may resemble either lymphatic or
myelogenous leukemia. Leukemoid reactions of the
lymphatic type are seen commonly in infectious mono-
nucleosis and in pertussis. In this paper we shall be con-
cerned only with the myeloid type of reaction.

Literature

Krumbhaar 1 classifies leukemoid reactions into "(a)
those that present real difficulty in diagnosis from leu-
kemia; and (b) those that have hematologic similarity
only.”

Heck and Hall 2 enumerate a number of conditions
in which leukemoid reactions of the myeloid type may
occur. Among these are: (I) active regeneration of the
bone marrow (as in acute hemorrhage) ; (2) severe in-
fections; (3) blood dyscrasias or reticulo-endothelial dis-
eases (such as congenital hemolytic icterus) ; (4) dis-
eases in which there is invasion and irritation of the bone
marrow (as in metastatic carcinoma; and (5) chemical
poisoning (as with mustard gas) .

Downey, Major, and Noble 3 report four cases that
showed leukemoid blood pictures of the myeloid type.
Three of these cases occurred in the same family follow-
ing the use of mercurial ointment. In these cases the
blood picture was practically identical with that of
chronic myelogenous leukemia.

Fitzhugh 4 lists the causes of leukemoid reactions as:
(1) severe infection; (2) eosinophilic leukemoid reaction
in trichiniasis and occasionally in Hodgkin’s disease or
tuberculosis of the glandular type; (3) noninfectious
states, especially carcinoma with bone metastases. He
also states that a monocytic type of reaction may be
found in (1) neoarsphenamine therapy of syphilis; (2)
in rapidly advancing tuberculosis; (3) during the early
recovery phase of agranulocytic angina; and (4) in
Streptococcus viridans septicemia.

Lederer 5 reports three cases in which there was a pro-
found anemia and a leukemoid reaction. In one case the
white blood count was 33,615 with 55 per cent polys,
0.5 per cent eosinophiles, 8 per cent monocytes, 24.5
per cent small lymphocytes, 2.5 per cent myelocytes, and
8 per cent metamyelocytes. He states that the "blood
smear showed in small quantities every type of cell asso-
ciated with myelogenous leukemia.”

Castle and Minot '' state that in acute hemolytic ane-
mia of the Lederer type leukocytosis with immature my-
eloid cells is the rule, but leukopenia has been reported.

O’Donoghue and Witts ‘ report that there is usually
a leukocytosis in acute hemolytic anemias, and that the
blood picture may closely resemble leukemia. In fact,

the symptomatology and the blood picture in acute leu-
kemia and Lederer’s anemia may be identical, with only
the subsequent course determining the diagnosis. They
feel that the cases cited in the literature as cures of
leukemia probably belong to the latter group.

Case Summaries

Case 1. This 12-year-old white male was seen June 14,
1942, with a history of vomiting and abdominal pain of
one week’s duration. There had been rather rapidly in-
creasing pallor and a temperature elevation up to 100°.
He had spent several winters in the tropics. He had
always tended to have a low-grade anemia, according to
his mother. He had an appendectomy in the spring
of 1941 and in the fall of 1941 a possible rupture of
the spleen, from which he recovered without recourse
to surgery.

Physical examination showed a chronically ill child
with a subicteric tint of the skin. His mucous mem-
branes showed a marked pallor. There was a generalized
lymphadenopathy. A systolic murmur was heard over
the apex of the heart; it was interpreted as hemic in
origin. The spleen was palpable two fingers below the
costal margin.

The laboratory findings were as follows: Hgb., 22

per cent; RBC, 1,830,000; WBC, 20,400; polys, 57 per
cent; lymphs, 14 per cent; monocytes, 2 per cent; meta-
myelocytes, 2 per cent; promyelocytes, 1 per cent; my-
elocytes, 19 per cent; normoblasts, 9 per 100 WBC
counted; nucleated reds, 13 per 100 WBC counted;
icterus index, 8.7; blood culture, sterile. Fragility test :
Patient hemolysis, began .50 per cent saline; complete,
.30 pier cent saline. Control hemolysis, began .42 per
cent saline; complete, .34 per cent saline.

Pathologist’s report : "Reds are hypochromic, baso-

philic, and show large numbers of nucleated forms. Nu-
merous microcytes are present. White cells and lymph-
ocytes show no change. Myeloid cells show immaturity
going back as far as promyelocytes. Impression: chronic
myelogenous leukemia.”

Subsequent Course. The child was given four trans-
fusions of citrated blood and at the time of discharge
from the hospital showed a marked improvement. On
June 26, 1942, his hemoglobin was 60 per cent; WBC,
6300, with 46 per cent PMN’s, 46 per cent lymphocytes,
4 per cent monocytes, 1 p>er cent eosinophiles, I pier cent
basophiles, and 1 per cent myelocytes. The nucleated
reds had disappeared from the blood smear. He was
given liver extract by injection and liver-iron prepara-
tions by mouth. He continued to be in fairly good
health at home, although the spleen was always palpable.

In March 1943 laboratory findings were: Hgb., 68.2
per cent; RBC, 3,640,000; color index, .94; average

May, 1946

167

diameter of red cells, 7.2 microns. Fragility test: Pa-
tient hemolysis, began .50 per cent saline; complete, .40
per cent saline. Control hemolysis, began .46 per cent
saline; complete, .34 per cent saline.

The blood smear showed no signs of immaturity in
either red or white cells. The van den Bergh test was
delayed. The icterus index was 9.4 units, and the stool
showed 112 mg. a day of urobilinogen excreted.

Splenectomy was considered, but was never carried
out. A recent report from the family physician stated
that the boy’s hemoglobin was around 70 per cent. He
has been getting liver extract intramuscularly at weekly
intervals. There has been no recurrence of the hemo-
lytic crises.

Final diagnosis : Hemolytic icterus, acquired type.

Case 2. This 7-year-old female was seen in consulta-
tion with Dr. T. J. Devereaux on April 26, 1945. Her
chief complaints were paleness for four days and vomit-
ing for four days. Her parents, in retrospect, had no-
ticed gradually increasing pallor for two weeks, but she
had been able to attend school until six days before her
admission. On April 20, 1945, she began to complain
of headache and abdominal pain. She had several
emeses. An elevated temperature was noted for the first
time on the morning of admission.

Her past history was noncontributory, and her fam-
ily history was negative except that a maternal grand-
mother had had some type of jaundice that persisted
about one year during her twentieth year.

Physical examination showed an acutely ill, semicoma-
tose, pale girl with a suggestion of an icteric tint of the
skin. Temperature was 103°, pulse 140, respiration 28.
A systolic murmur heard over the apex of the heart was
hemic in origin. The tip of the spleen was barely
palpable.

The laboratory findings were as follows: Hgb., 14

per cent; RBC, 1,140,000; WBC, 22,750; PMN’s, 63
per cent; lymphs, 17 per cent; monocytes, 3 per cent;
basophiles, 2 per cent; myelocytes, 6 per cent; juvenile,
6 per cent; promyelocytes, 2 per cent; stem cells, 2 per
cent; icterus index, 18. Fragility test: Patient hemolysis,
began .44 per cent saline; complete .38 per cent saline.
Control hemolysis, began .42 per cent saline; complete
.32 per cent saline.

Blood morphology: "Red blood cells show anisocytosis
with some microcytosis; there are four normoblasts per
100 WBC and moderate to marked polychromasia with
moderate hypochromasia. PMN’s show immature stages
of development from stem cells to mature forms. Im-
mature forms are in relatively low percentage. Platelets
are normal in number and morphology. Leukemoid
reaction to be ruled out, but picture would support diag-
nosis of myelogenous leukemia.”

The patient was given three transfusions of citrated
blood and made a most dramatic improvement. The
fever subsided and the signs of immaturity in the white
cells disappeared. She was discharged from the hospital
on May 4, 1945, with a hemoglobin of 58 per cent. The
diagnosis at that time was acute hemolytic anemia,
Lederer type. She remained at home for ten days and
then was readmitted because of a return of symptoms.
At this time her hemoglobin was 38 per cent, with 8550
WBC. Smears showed microcytosis and spherocytosis.
The mean diameter of the red cells was 6.7 microns.
The spleen was now definitely palpable two fingers
below the costal margin. There was an increased fra-
gility to hypotonic salt solution. The fecal urobilinogen
was 601 mg. per day.

She was given repeated blood transfusions, and on
May 21, 1945, splenectomy was done. She made an
uneventful postoperative recovery and was discharged
ten days later in excellent condition.

Section of the spleen showed "the follicles to be
prominent. The pulp is markedly congested with large
numbers of red cells. The picture is compatible with
a congenital hemolytic icterus.”

Studies were made of the parents and a younger
brother. Fragility tests, blood smears, and measurements
of the size of the red cells were all within normal limits.

The final diagnosis was hemolytic icterus, acquired
type.

When last seen in August 1945, the patient’s hemo-
globin was 90 per cent and her RBC 4,600,000. There
was a slight increase in fragility above normal. The
blood smear still showed microcytosis and spherocytosis.
The average mean diameter of the red cells was 6.8
microns.

Summary

Two cases of hemolytic icterus, which during hemo-
lytic crisis closely resembled myelogenous leukemia, are
presented.

References

1. Krumbhaar, E. B.: Leukemoid Blood Pictures in Various
Clinical Conditions. Am. J. M. Sc., 172, 519-33 (Oct.), 1926.

2. Heck, F. J., and Hall, B. E.: Leukemoid Reactions of
the Myeloid Type. J.A.M.A., 112, 95—101 (Jan. 14), 1939.

3. Downey, Hal, Major, S. G., and Noble, J. E.: Leukemoid
Blood Pictures of the Myeloid Type. Folia haemat., 41, 493—
511 (July), 1930.

4. Fitzhugh, Thomas, Jr.: Leukemoid Blood Reactions. Penn-
sylvania M. J., 35, 290-93 (Feb.), 1932.

5. Lederer, Max: A Form of Acute Hemolytic Anemia

Probably of Infectious Origin. Am. J. Med. Sc., 170, 500,
1925.

6. Castle, W. B., and Minot, G.: New York: Oxford Medi-
cine, 2:624.

7. O’Donoghue, R. J L., and Witts, L. J.: The Acute

Hemolytic Anemia of Lederer. Guy’s Hosp. Reports, 82, 440,
1932.

168

The Journal Lancet

. . . fllEET OUR COflTRIBUTORS . . .

Note. Most of the papers published in this issue were pre-
sented at the Fall meeting of the Northwestern Pediatric So-
ciety, held at White Pine Inn, Bayport, Minnesota, September
28, 1945.

Dr. Erling S. Platou, special editor of this issue, is
a graduate of the University of Minnesota with the
degrees of B.S., M.B., and M.D., and pursued graduate
work for four years in New York, Boston, and Europe.
Besides his private practice in pediatrics in Minneapolis,
he is clinical professor of pediatrics at the University of
Minnesota. He is past president of the Northwestern
Pediatric Society and a member of the American Acad-
emy of Pediatrics, the American Board of Pediatrics,
and Sigma Xi.

Dr. Jay Arthur Myers, who contributes the "per-
sonal appreciation” of Dr. Stewart, is the well-known
Minneapolis physician.

Dr. Alexander Ashley Weech of the Cincinnati
Children’s Hospital is a graduate of Johns Hopkins
Medical School. He is professor of pediatrics, Univer-
sity of Cincinnati; medical director of the Children’s
Hospital and Pediatric Division of the Cincinnati Gen-
eral Hospital; and director of the Children’s Hospital
Research Foundation. He is a member of the Council,
American Pediatric Society, and holds memberships in
the Society for Pediatric Research, the American Acad-
emy of Pediatrics, the Society for Research in Child
Development, the Society for Experimental Research and
Development, and the Harvey Society.

Dr. Richard Beresford Tudor, clinical assistant in
pediatrics at the University of Minnesota, is a graduate
of the University with the degrees of A.B., M.B., and
M.D. (1941), with graduate work in pediatrics at Duke
University Hospital and Bellevue Hospital, New York
City, on the New York University Service.

Dr. George Bryan Logan has been associated with
the Mayo Clinic, where he is consultant in pediatrics,
since 1937. He is a graduate of Harvard Medical School
(1934), with graduate work at the Mayo Foundation
(M.S. in Pediatrics, 1940). He is president of the
Northwestern Pediatric Society and holds memberships
in the American Academy of Pediatrics, the American
Medical Association, and Sigma Xi.

Dr. Haddow Macdonnell Keith has been associ-
ated with the Mayo Clinic, where he is consultant in
pediatrics, for eleven years. He is a graduate of the
University of Toronto Medical School (M.B., 1924),
with graduate work at Henry Ford Hospital, Detroit,
the University of Rochester, the Montreal Neurologic
Institute, and the Hospital for Nervous Diseases, Lon-
don. He has been president of the Minnesota Mental
Hygiene Society (1939-42), and vice-president of the
Epilepsy League (1944—45). He is a member also of
the American Academy of Pediatrics, Sigma Xi, the
American Medical Association, the Northwestern Pedi-
atric Society, the Canadian Society for the Study of

Diseases of Children, and the Central Society for Clin-
ical Research. He was Traveling Fellow of the Mon-
treal Neurological Institute in 1934-35.

Dr. Ralph T. Knight, clinical professor and director
of the Division of Anesthesiology, University of Minne-
sota, is a graduate of the University of Minnesota Med-
ical School (M.D., 1912), with graduate work in his
specialty, anesthesiology, at the Mayo Foundation. He
was vice-president of the American Society of Anesthesi-
ologists in 1945 and a fellow of the American College
of Surgeons.

Dr. Joseph T. Cohen of Minneapolis, assistant clin-
ical professor of pediatrics at the University of Minne-
sota, has done considerable research in his special field,
children’s dentistry. He is a member of the International
Association of Dentistry for Children.

Dr. M. M. Litow, formerly associated with Dr.
Cohen in the practice of dentistry, is now in California.

Dr. Laurence G. Pray of Fargo, North Dakota,
is a graduate of the Washington University Medical
School (1935), with graduate work at Johns Hopkins
Hospital, the Babies’ Hospital of New York, and the
St. Louis Children’s Hospital. He is a member of the
Northwestern Pediatric Society, the American Academy
of Pediatrics, and the North Dakota State Medical
Association, and a Licentiate of the American Board of
Pediatrics.

Dr. Ralph Edwin Dyson of the Northwest Clinic,
Minot, North Dakota, has practiced there for 11 years.
He is a graduate of the State University of Iowa Med-
ical School (M.D. ,1932), with graduate work at the
University of Minnesota. He is state chairman of the
American Academy of Pediatrics.

Dr. Robert W. Gibbs, who holds a two-year residency
at Minneapolis General Hospital, is a graduate of the
University of Minnesota Medical School (B.A., M.B.,
M.D., 1943).

Dr. Forrest H. Adams of the University of Minne-
sota Pediatrics Department is also a graduate of the
University (M.B., M.D., M.S.). He has just entered
the Navy and is located at the San Diego Naval Hos-
pital.

Dr. Hyman S. Lippman, director and psychiatrist of
the Amherst H. Wilder Child Guidance Clinic, St. Paul,
has practiced in the Twin Cities since 1923. He is a
graduate of the University of Minnesota Medical
School, with the degrees of M.D. and Ph.D. in Pediat-
rics, and studied also in New York and Vienna. He is
president of the Minnesota Society of Neurology and
Psychiatry and a member of the American Psychiatric
Society, the American Orthopsychiatric Association, the
American Psychoanalytic Society and the Chicago Psy-
choanalytic Society, as well as the American Medical
Association and the Northwestern Pediatric Society and
Sigma Xi.

(Continued on page 174)

jotr

LATiCET

Serves the

MINNESOTA, NORTH DAKOTA,

Medical Profession of

SOUTH DAKOTA and MONTANA

North Dakota State Medical Assn. South

Dr. James F. Hanna, Pres. Dr.

Dr. A. E. Spear, Pres. -Elect Dr.

Dr. L. W. Larson, Secy. Dr.

Dr. W. W. Wood, Treas. Dr.

North Dakota Society of South

Obstetrics and Gynecology Dr.

Dr. E. H. Boerth, Pres. Dr.

Dr. Paul Freise, Vice Pres. Dr.

Dr. G. Wilson Hunter, Secy .-Treas.

Sioux

Minneapolis Academy of Medicine Dr.

Dr. Karl W. Anderson, President Dr.

Dr. Russell W. Morse, Vice Pres. Dr.

Dr. J. C. Miller, Secretary Dr.

Dr. Ragnvald S. Ylvisaker, Treasurer
Dr. Henry E. Hoffert, Recorder

Dr J . O. Arnson
Dr. A. B. Baker
Dr. D. S. Baughman
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. H. S. Diehl
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Dr. Ralph V. Ellis
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Dr. A. R. Foss
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Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. J. Mabee

ADVISORY COUNCIL

Dakota State Medical Assn.
William Duncan, Pres.

F. S. Howe, Pres.-Elect
H. R. Brown, Vice Pres.
Roland G. Mayer, Secy.-T reas.

Dakota Public Health Assn.

J. M. Butler, Pres.

C. E. Sherwood, Vice Pres.
Gilbert Cottam, Secy.-T reas.

Valley Medical Assn.

D. S. Baughman, Pres.

Will Donahoe, Vice Pres.

R. H. McBride, Secy.

Frank Winkler, Treas.

BOARD OF EDITORS

Dr. J. A. Myers, Chairman

Montana State Medical Assn.

Dr. S. A. Cooney, Pres.

Dr. M. A. Shillington, Pres.-Elect
Dr. R. F. Peterson, Secy. -Treas.

Northwestern Pediatric Society
Dr. G. B. Logan, Pres.

Dr. Geo. Kimmel, Vice Pres.

Dr. Northrop Beach, Secy. -Treas.

Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.

Dr. R. C. Webb, Secy. -Treas.

American Student Health Assn.

Dr. Ralph I. Canuteson, Pres.

Dr. Glenadine Snow, Vice Pres.

Dr. G. T. Blydenburgh, Secy. -Treas.

Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C H Nelson
Dr. N. J . Nessa
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. C. E. Sherwood

Dr. M. A. Shillington
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Dr. W. H. Thompson
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LANCET PUBLISHING CO., Publishers , 84 South Tenth Street, Minneapolis 2, Minnesota

Minneapolis, Minnesota, May, 1946

DR. CHESTER ARTHUR STEWART
AT LOUISIANA
1941-1946

Nature, by and large, is chary of her bounties. She
is selective in the distribution of her gifts and bestows
them sparingly. To one man she may give a keen scien-
tific mind and a real love of research; to another, a deep
consciousness of the social needs of his fellow men and
the leadership to persuade others to meet these needs;
to a third, the almost prophetic vision of the future
which enables him to plan well; to still another, the
priceless gift of a pleasing personality that captures the
hearts of men; and to yet another, that rare gift of
clear exposition which makes a man an unrivaled teacher,
with the ability to expound scientific knowledge so clearly
that he who runs may read and understand.

Among our acquaintances and friends we frequently
meet men who exemplify one or another of these great
qualities, but rarely do we find one who is endowed with

all of them. Dr. Chester Arthur Stewart was such a
man, however. Nature was lavishly generous in giving
him all these great virtues. His scholarly mind and his
love of research were attested to by the many scientific
papers he published in his chosen field, pediatrics. These
papers numbered about eighty. He was singularly blessed
also with a clear mind and a grasp of both final objec-
tives and intervening details which made him a great
administrator and organizer. To this, as a complement,
was added his ability to get on with others, to lead them
—not drive them — with a minimum of friction and a
maximum of co-operation that confirmed his ability as
a leader. His unfailing good humor, wit, and jolly tem-
perament, coupled with his outstanding ability and his
great humanity, endeared him to all the medical stu-
dents, nurses, interns, residents, and faculty members
with whom he was associated.

It was the good fortune of the medical world of New
Orleans to have the privilege of associating with Dr.

109

170

The Journal Lancet

Stewart for about five years. It was too short a period
to have derived all the inspiration and help that this
truly outstanding physician could have given us, yet
long enough to have our outlook broadened and en-
riched to an extent that gave all with whom he came
in contact a realization of the man’s sterling qualities.

As a clinician, Dr. Stewart was unexcelled; to research
problems he brought enthusiasm and critical faculties
that made his work outstandingly dependable. His ap-
praisal of the efforts of others in the field of investiga-
tion was almost infallible, and in the field of public
health his work was as constructive and fruitful as in
the clinical field.

At the time of his death Dr. Stewart served the
School of Medicine of Louisiana State University in the
dual capacity of director of the department of pediatrics
and chief of the pediatrics unit of the university at the
Charity Hospital of Louisiana at New Orleans. He
gave generously of his time to the school, not only in
his teaching and departmental administrative capacity,
but also as a member of the Faculty Executive Com-
mittee. Here his great power of organization, adminis-
tration, and planning for the future were of inestimable
value. His death was an unexpected blow from which
the school will not soon recover. The scientific com-
munity of the South has lost one of its outstanding fig-
ures, and clinical medicine one of its ablest men.

G. W. McCoy, M.D.

SAVING THE CHILDREN

News about the welfare of children in a single recent
issue of The New York. Times offers cause for both
despair and rejoicing.

Reporting on a tour of the liberated countries, Mary
Craig McGeachy, director of welfare for UNRRA, said:
"In Prague they gave tests and X-rays to 70,000 school
children and found that 40 per cent showed signs of
lung disorder. In Greece the incidence of tuberculosis
increased four and one half times during the war years.
In Yugoslavia the case rate and death rate doubled.
In Italy the death rate rose two and one half times.
In countries of the west, while the general figures are
less startling, there are bad spots.” It is no longer merely
a question of providing food in special clinics for chil-
dren and for vulnerable groups of the population, she
said, but of whether even the able-bodied will survive
the trial of the coming months.

In Boston, meanwhile, after a year and a half of
study, plans have been announced for the creation of a
medical center for children, with the Boston Children’s
Hospital as a nucleus and with affiliates throughout the
country to extend aid to any child in need of its service.
Plans are being made to provide for training increased
numbers of physicians and nurses and for added med-
ical research and care for adolescents. The hospital in
the past has treated more than 60,000 children a year.
The need for such a center is nowhere better illustrated
than by the results of our selective service examinations,
according to the president of the hospital, J. W. Farley.
The hospital has a record of 77 years of service to chil-
dren, and has pioneered in pediatrics, research, and
treatment.

^beatliA,

Dr. J. H. Hunt, 84, pioneer physician of Glendive,
Montana, died March 25 in that city. Dr. Hunt, who
was born January 31, 1862, at Grant, Tennessee, came
to Glendive in 1890. He is survived by his wife, a son
and daughter, and a brother, Milford Hunt, of Patter-
son, Wisconsin.

Dr. George J. McHeffey, 41, of Butte, Montana, died
March 19 in that city. He was a veterans of 22 months’
overseas service with the Army Medical Corps, including
16 months in France as chief of the laboratory service
of General Hospital 203. He was released with the rank
of lieutenant colonel. Dr. McHeffey entered the service
from Billings, where he was a pathologist. He was a
graduate of the University of Michigan Medical School,
interned at Murray Hospital, and studied pathology at
the Mayo Clinic. He is survived by his wife, two daugh-
ters, and his mother.

Dr. Samuel E. Schwartz, 70, of Butte, Montana,
died March 30 at Butte, after a lingering illness. He
was born October 30, 1875, in New York City, and was
a graduate of the Columbia University College of Phy-
sicians and Surgeons (M.D., 1896). He came to Mon-
tana in 1898 and received his Montana license the fol-
lowing year. He was an Army captain in World War I.

Dr. Schwartz had maintained offices in the Owsley
Building in Butte for more than a third of a century.
He was past president of the Silver Bow County Med-
ical Society and the St. James Hospital medical staff,
a fellow of the American Medical Association, and a
member of the Montana State Medical Association. He
was also active in civic and musical affairs in Butte.

Dr. Martin Daniel Westley, 72, of Cooperstown,
North Dakota, died March 28 in Minneapolis. Dr.
Westley, who had practiced in Cooperstown for 42 years,
was born in Stavanger, Norway, November 27, 1873.
He was graduated from Jefferson Medical College,
Philadelphia, in 1904, and came to Cooperstown the
same year. He served 13 months during World War I
and was discharged with the rank of captain; in World
War II he served the draft boards by giving physical
examinations. He was a member of the state committee
on maternal and child welfare and for several terms was
coroner of Griggs County.

He is survived by his wife, three sons and a daughter,
a brother, and a sister.

Dr. William E. Rochford, 86, died in Minneapolis
April 3. A pioneer surgeon, he had served 50 years as
chief surgeon for the Milwaukee Road, and had also
been chief of staff of St. Barnabas and Northwestern
hospitals. He had maintained his practice despite 30
years of blindness, and retired only in 1945.

Dr. Rochford was a charter member of the American
College of Surgeons, a diplomate of the American
Board of Surgery, and a member of the Western Sur-
gical Board. He is survived by two daughters and three
sons.

May, 1946

171

Tuberculosis Among College Students

Fifteenth Annual Report of the Tuberculosis Committee, American Student Health
Association, for the Academic Year, 1944—45

As we reflect upon the progress of our work in the
k-past, and begin to think seriously of our increased
responsibilities for the future, let us consider the results
of our work for the last of the war years. Probably
owing to the effect of total mobilization for total war,
student health service has been somewhat curtailed dur-
ing the past two or three years. But even in spite of the
mobilization of our personnel and facilities for war, most
colleges and universities have been able to maintain rea-
sonably adequate health services, including programs for
tuberculosis control, especially if such programs had
already been in progress. Credit must certainly be given,
in no small measure, to those who have been responsible
for stimulating and maintaining interest in tuberculosis
as a menace to student health.

We Are Encouraged

Fewer replies were received to the 1944-45 question-
naire, sent to 885 colleges and universities, than in some
of the prewar years. But among these 461 replies a new
high of 312 colleges and universities reported some type
of tuberculosis program.

Undoubtedly many factors have contributed to this
increase. We should like to think it a result of the
combined efforts of several related agencies, all striving
for one ultimate goal, the elimination of tuberculosis.
Evidence is accumulating that county and state anti-
tuberculosis organizations are interesting themselves in
our work. Many such organizations have colleges in
their communities. They are no doubt aware that their
local college is either making an excellent contribution to
the cause of tuberculosis control, or is doing nothing in
this respect. Repeated demonstration of the now trite
fact that "tuberculosis is found where looked for” may
be having its hoped for effect.

We welcome this interest on the part of both official
and nonofficial agencies, and should like to see it in-
crease. The most fruitful field for further progress in
our work seems to be in the area of the smaller college.
Many small colleges are not in a position to support
their own student health service. They need encourage-
ment and help, both of which could be furnished by
organized anti-tuberculosis groups. Through mutual co-
operation between colleges and tuberculosis associations,
tuberculosis programs might be established on the cam-
puses of many of our smaller colleges where no program
is now in operation.

Further encouragement is obtained from the finding
of 389 cases of tuberculosis at colleges having some type
of tuberculosis program. And, with a feeling of real
accomplishment, we are able to report 581 students, for-
mer cases of tuberculosis now arrested, returning to their
college careers.

TABLE 1

Colleges and Universities Sent Questionnaires, Replies Received, and
Programs Reported for the Academic Year 1944—45, Classi-
fied by States, and a Comparison with Former Years

Colleges sent

Replies

Programs

Division and State

Questionnaire

Received

Reported

United

States 885

461

312

New England

Maine

New Hampshire

Vermont

Massachusetts

Rhode Island

Connecticut

Middle Atlantic

150

New York

New Jersey

1 3

Pennsylvania

East North Central

169

107

Ohio

I ndiana

Illinois

Michigan

Wisconsin

West North Central

127

Minnesota

Iowa

Missouri

North Dakota

South Dakota

Nebraska

1 5

Kansas

1 5

South Atlantic

118

Delaware

—

Maryland

District of Columbia

Virginia

West Virginia

1 1

North Carolina

1 3

South Carolina

1 5

Georgia

Florida

East South Central

Kentucky

T ennessee

Alabama

Mississippi

West South Central

Arkansas

1 1

Louisiana

1 3

Oklahoma

Texas

1 1

Mountain

Montana

Idaho

—

Wyoming

Colorado

New Mexico

—

Arizona

—

Utah

Nevada

—

Pacific

Washington

Oregon

California

1 1

Grand Total
1945 ....
1944
1943
1942
1941
1940

NOTE: Colleges and universities in all but two states replied

to our questionnaire this year. Programs were reported in all but
five states, a gain of one state over the preceding year. Since every
state has at least one college we must work for 100 per cent rep-
resentation of the United States.

885 461 312

886 400 286
879 398 267
860 488 311
854 483 304
877 475 248

172

The Journal Lancet

TABLE 2

American Colleges and Universities which Answered the Question-
naire, Classified by Student Enrollment for the
Years 1943-44 and 1944-45

Student Enrollment

Number

1944-45

of Colleges

1943-44

Total

461

400

Colleges with:

Fewer than 500 students

263

234

500 but less than

1000

students

1000 but less than

2000

students

2000 but less than

3000

students

3000 but less than

4000

students

1 4

4000 but less than

5000

students

5000 but less than

6000

students

NOTE: Number of students enrolled in American colleges and

universities co-operating in the tuberculosis survey for 1943—44
was 411,313; for 1944-45 the number enrolled was 468,016.

But Not Unduly Optimistic

Whatever feeling of encouragement we may obtain
from the foregoing paragraphs, we must admit there is
much room for improvement. Almost 50 per cent of
colleges contacted still do not answer our questionnaire.
Only about 35 per cent report a tuberculosis program.
(Of those who replied, 68 per cent have a program.)
Some of the replies could not be used for statistical pur-
poses because they failed to include, or to elucidate upon,
one or more of the items.

Reports from 149 colleges with no tuberculosis pro-
gram again reveal the interesting fact that some tuber-
culosis is discovered even when not especially looked for
(Table 3). However, considering that in colleges with no
program only nine cases were discovered among 101,518
students (approximately nine cases per 100,000 students),
as compared to the 389 cases found among 357,714 stu-
dents attending colleges having some organized program
of tuberculosis control (approximately 109 per 100,000),
it is logical to assume that many students with undiscov-
ered tuberculosis were attending those colleges having no
program. Over twelve times as many cases were found
in colleges where a program was in effect. Even in spite
of the repeated demonstration of such a comparison,
colleges continue to report "no need for tests” on their
campuses.

The Tuberculin Test Is Used Here

One hundred ninety-one colleges report the use of the
tuberculin test, in some form, as part of their tubercu-
losis program. We believe that second only in impor-
tance to the actual finding of cases of tuberculosis is
the determination of the extent of tuberculous infection.
This can be done only by tuberculin testing, because the
tuberculin test is the easiest and most certain method for
demonstrating the presence of living tubercle bacilli in
the body of an infected person. As long as we have
tuberculin reactors we shall have cases of tuberculosis.
The tuberculin test is therefore valuable as an index of
our success in the control of this disease.

The committee has for some time recommended the
use of Purified Protein Derivative (PPD), given in two
doses by the method of Mantoux, as the ideal screening
procedure. Nothing up to the present time has changed
this decision. An intradermal method is preferred, be-
cause when tuberculin is thus injected the allergen will

TABLE J

Cases of Tuberculosis Found in Colleges with Tuberculin Testing
Programs, in Those with X-ray Programs only, and in
Those with No Tuberculosis Programs, Classified
by College Group and Disposition of Cases

College group and
disposition of cases

Cases found
in 175 col-
leges with
tuberculin
testing
programs
(enrollment

231,735)

Cases found
in 121 col-
leges with
X-ray pro-
grams only
(enrollment
125,979)

Cases found
in 1 49 col-
leges with no
tuberculosis
programs
(enrollment
101,518)

Student body

181

208

Students who have with-
drawn from college

108

Believed to have en-
tered sanatoriums

Believed to be
under treatment
at home

Treatment
not reported

Faculty, administrative

staff, etc.

College food handlers

Other college employees

—

Students now back in college
with arrested disease,
previously diagnosed

379

164

be placed in intimate contact with the tissues. Exact
dosage is certain and results will be more uniform.

Reports from 175 colleges and universities with en-
rollment of 231,735 students could be used for the fig-
ures relating to students tested and reactors found. It
should be noted that only 91,599 students were reported
as having been tested. Our conclusion is that 140,136
students were not included in the tuberculosis programs
of these colleges. Perhaps the majority of students not
surveyed were in the upper classes, since many schools
test only new students, while a few include one or more
of the upper classes. The ideal is difficult of attainment,
as all of us confronted with the problem well know. We
shall continue to miss cases unless all students are tested,
retested annually as long as they are nonreactors, and
X-rayed annually whenever they are found to be reactors.

Inquiries continue to come in about the relative value
of the Vollmer Patch Test. This method of testing
seems to have as its main appeal the fact that it does
not require the use of a needle. Certainly there is little
evidence that it is as efficient. The percentage of reactors
discovered by its use has been consistently less than found
with our recommended testing procedure — PPD given
in two doses by the Mantoux method. Some authorities
believe that "significant” tuberculosis may be brought to
light regardless of the method of testing. But as long
as the committee contends that it has an important obli-
gation to demonstrate the incidence of tuberculous in-
fection (tuberculin reaction), it cannot endorse a method
of testing that admittedly gives fewer reactors. If we
are seeking only "significant” tuberculosis we have done
nothing for the potential case of the person who harbors
the germ in his body, or for the community where lives
the person who transmitted this infection.

But Some Use Only the X-ray

One hundred twenty-one colleges report the use of the
X-ray alone as their method of choice for tuberculosis
case finding. This is an increase of 37 over last year,

May, 1946

173

when 83 made this report. We do not wish to condemn
this practice too severely, because, obviously, cases of
tuberculosis are discovered when X-ray alone is used as
the survey method. However, the committee believes
that the following statements should be considered seri-
ously, particularly if a college is contemplating a change
from a tuberculin testing program to one using only the
X-ray.

We have already called attention to one of these fac-
tors in discussing our obligation to demonstrate the inci-
dence of tuberculous infection. X-ray cannot, with any
degree of certainty, tell us who has and who has not
been infected with the germ of tuberculosis. Many chest
findings which in the past have been considered as evi-
dence of "healed” or "calcified” tuberculous lesions have
been shown to be due to causes entirely nontuberculous.
Ascaris and coccidioidomycosis have been cited as causes
of pulmonary calcifications. More recently Histopldsma
cdpsuldtum has been indicated as "probably the princi-
pal non-tuberculous cause of pulmonary calcifications.”*
This finding may help to explain why so many people
have been found to have pulmonary calcifications al-
though they were nonreactors to tuberculin.

The X-ray tells us but one of two things. The chest
is either clear and negative or normal or there is an ab-
normal finding. If a diagnosis of "normal chest” is made
in a mass survey, the person to whom that chest belongs
is forgotten. If the tuberculin test is used first, it offers
an opportunity for the physician, even in the brief time
it takes to read and record the result, to explain the sig-
nificance of the result. Student health service, in addi-
tion to supplying medical aid to students, must justify
itself as a function of the college or university by con-
tributing to the education of students. Few health serv-
ice procedures have a potential for health education com-
parable to the tuberculin test. There is far more incen-
tive for repeated X-ray, we believe, with remembrance
of a tuberculin reaction as a warning.

And the Techniques Are Diversified

A summary of the results obtained from the 1944-45
questionnaire brought to light many interesting findings.
Some of these have been used in shaping the content of
the foregoing discussion. In addition to what has already
been said, we wish to call attention to the marked varia-
tion in techniques used by American colleges and univer-
sities in their tuberculosis control programs.

These variations may prove of value in the long-range
study of optimum measures for an ideal program. Hun-
dreds of colleges with total enrollment of thousands of
students make an exceptional proving ground in this
respect. Our aim is to keep before the American Stu-
dent Health Association, and others, the trend of tuber-
culous infection among an appreciable segment of the
age group that produces a large number of cases of this
disease. By trying this and testing that, and by compar-
ing the results of all methods with the method we have
considered best, we may either change our ideal or fur-
ther prove its worth.

*Carroll E. Palmer, M.D.: Public Health Reports, 60: 513
(May 11), 1945.

TABLE 4

Techniques Used in Survey Programs, Showing Number of
Colleges Using Each Technique

I. Colleges reporting tuberculin testing program
Testing Method:

Mantoux intradermal 110 colleges

Vollmer patch test 52 colleges

Combination patch and Mantoux 5 colleges

Combination of Mantoux and Corper 1 college

Unspecified 3 colleges

Testing Material (exclusive of Vollmer):

Purified Protein Derivative 54 colleges

Old Tuberculin 59 colleges

Unspecified 4 colleges

Combination of PPD and OT 2 colleges

Testing Dosage:

Two-dose technique 33 colleges

Single large dose 8 colleges

Single intermediate dose 32 colleges

Single small dose 12 colleges

Single dose (strength not specified) 1 3 colleges

Three-dose (U. of Calif. Med. School) 1 college

Combination of dosage 1 college

Unspecified 19 colleges

Testing Routine:

All new students, negative reactors annually

(or oftener) 62 colleges

Freshmen and new students only 52 colleges

All students 1 0 colleges

New students and seniors 1 2 colleges

New students and negatively reacting seniors 6 colleges

Other testing routine* 15 colleges

Unspecified 1 4 colleges

•Included nearly 15 different variations. One college even

reported that all new students were both tested and X-rayed.
(This could be the answer to the objection that nontubercu-
lous chest pathology may be missed if only the chests of
positive reactors are X-rayed.)

Routine for X-raying tuberculin reactors:

Reactors filmed annually (or oftener) 90 colleges

Reactors filmed once only _ 48 colleges

X-ray optional 4 colleges

Unspecified 7 colleges

Other X-ray routine* 22 colleges

•Six colleges report the use of the fluoroscope for their
tuberculin reactors. We do not favor this practice because it
leaves no permanent record for comparison.

II. Colleges reporting X-ray program

X-ray routines reported:

X-ray new students only 28 colleges

X-ray all students _ 20 colleges

X-ray all students annually ... 15 colleges

X-ray old students every two years 3 colleges

X-ray new students and seniors 13 colleges

X-ray optional for students 8 colleges

Routine not reported 30 colleges

X-ray new students, optional for others 2 colleges

Fluoroscope used for screening process* 2 colleges

•One of these colleges X-rays students whose fluoroscopic
findings are positive. (This procedure partially overcomes
our objection to relying solely on the fluoroscope.)

We have already suggested that tuberculosis control
work, especially when tuberculin testing is used, enhances
the role of the health service as an educational function
of the college or university. Ending the report of this
committee for the year 1938-39 was the slogan "Edu-
cate the educators concerning tuberculosis.” Education
is a continuing process and that slogan must be pro-
claimed repeatedly. It should also be extended to include
health service personnel, especially the directors of health
service programs.

What we know about tuberculosis is not static, it is
continuously changing. We now know, for instance,
that the diagnosis of tuberculosis in its minimal stages —
which is the best time to discover the disease for all con-
cerned— does not depend on our eliciting a history of
suggestive symptoms or of finding obvious physical signs
on examination. Discovery depends on looking for this
disease in apparently healthy people. It is best accom-
plished by tuberculin testing everyone and X-raying the

174

chests of reactors, repeating this process annually. Sev-
eral schools X-ray reactors only if advised to do so by
the college physician or if desired by the reactor! No —
our job of health education is not complete if we end it
with attempts to "educate the educators.”

Non-Student Participation Needs To Be
Encouraged

A number of colleges, though not nearly enough, we
think, are including non-student members of the campus
community in their tuberculosis program. It has for
some time been the opinion of this committee that if a
program of tuberculosis control is attempted on any
college campus it is a mistake to neglect anyone. Tuber-
culosis, a contagious disease, is found in all age groups
and in all walks of life. We cannot hope to protect our
students from tuberculous infection if we are not sure
of the absence of this disease in their instructors; in
the maid who cleans their rooms; in the house mother
in the rooming house or dormitory; in the food handler
who prepares or serves their food.

And Finally

The past findings of the Committee on Tuberculosis
of the American Student Health Association have been
observed and quoted by many other agencies interested
in the control of tuberculosis. Our organization has set
standards in the control of this disease, and remarkable
results have been produced. In order to maintain our
record and to improve it we must not slacken our efforts.

Enrollments have begun to increase, and predictions are
that an unprecedented number of students will be enter-
ing our colleges and universities. Our present facilities
will be taxed to the limit, and there is already talk of
the necessity for establishing new colleges. Some of us
may believe that the majority of these new students, and
old ones returned, will already have their tuberculosis
status determined. This is especially so regarding vet-
erans who have had an X-ray on separation from the
service. However, we must bear in mind that reports
have been received of cases missed on separation from
the service. Other veterans will develop tuberculosis as
a result of exposure to the disease while in service. All
new students, as well as former students who are now
returning to our campuses, should enter on exactly the
same basis the tuberculosis program of the college they

The Journal Lancet

decide to attend. Ours is an all-out program of tuber-
culosis control.

We must not end this report without again thanking
the National Tuberculosis Association for the time and
effort they have contributed to make this survey and
former ones successful and profitable. We should like
especially to call attention to the appointment of Mr.
Arthur H. Stiefel, Assistant in Health Education of the
National Tuberculosis Association, to the special job of
assisting your committee in any way possible.

Respectfully submitted,

Committee on Tuberculosis:

Paul B. Cornely, M.D.

J. P. Ritenour, M.D.

Orville Rogers, M.D.

Max L. Durfee, M.D., Chairman
Advisory Committee:

J. Burns Amberson, M.D.

Esmond R. Long, M.D.

Charles E. Lyght, M.D.

J. A. Myers, M.D.

Henry C. Sweany, M.D.

Membership of the Committee on T uberculosis:

Paul B. Cornely, M.D.

Howard University, Washington, D. C.

J. P. Ritenour, M.D.

Pennsylvania State College, State College, Pennsylvania
Orville Rogers, M.D.

Yale University, New Haven, Connecticut
Max L. Durfee, M.D., Chairman

Iowa State Teachers College, Cedar Falls, Iowa

Advisory Members:

J. Burns Amberson, M.D.

Bellevue Hospital, New York City
Esmond R. Long, M.D.

The Henry Phipps Institute, Philadelphia
Charles E. Lyght, M.D.

National Tuberculosis Association, New York City

J. A. Myers, M.D.

University of Minnesota, Minneapolis
Henry C. Sweany, M.D.

Municipal Sanatorium, Chicago

MEET OUR CONTRIBUTORS

(Continued from page 168)

Dr. William E. Proffitt has practiced in Minne-
apolis for seven years, with two years out for military
service. He is a graduate of the University of Minne-
sota (B.A., M.B., and M.D., 1939), with graduate
work on the pediatric staff of Minneapolis General
Hospital. He is secretary-treasurer of the St. Barnabas
Hospital staff. He is a member of the "M” Club of
the University of Minnesota for athletics.

Dr. Oswald S. Wyatt, co-author of the article on
giant-cell tumor of bone, practices in Minneapolis.

Dr. Stuart Lane Arey, who practices pediatrics in
Minneapolis, is a graduate of the University of Minne-
sota (M.B., 1931, M.D., 1932), with graduate work at
Children’s Memorial Hospital, Chicago. He is a mem-
ber of the American Academy of Pediatrics, the North-
western Pediatric Society, and the American Medical
Association.

May, 1946

175

Views Item*

NEWS FROM MINNESOTA

Dr. Christopher Graham, for many years an associate
of the Doctors Mayo, observed his 90th birthday on
April 3, in Rochester, where, except for a few years,
he has spent his entire life. Dr. Graham retired from
medical practice several years ago and became a breeder
of Holstein cattle, and at one time owned the world’s
champion milk producer. Dr. Graham, a graduate of
the University of Minnesota, was a member of the first
football team of the university in the fall of 1886, and
was also the first intern at St. Mary’s Hospital in
Rochester.

Dr. Kano Ikeda of the Charles T. Miller Hospital,
St. Paul, addressed members of the Arrowhead Society
of Medical Technologists on April 27.

Dr. E. G. Howard has resumed practice in Mapleton
after service with the Navy.

Dr. R. W. Dowidat, physician and surgeon, has
opened an office in Richfield. Formerly in Edina and
more recently in service, he is the first physician to locate
in Richfield.

Fourteen immunization clinics were held in Nobles
County and Fulda during the week of April 5.

Dr. Maurice B. Visscher of the University of Minne-
sota spoke on "Medicine and Contemporary Civilization”
on April 10 at the university, as part of the symposium
on Civilization in the United States.

Some fifty Minnesota physicians, mostly World
War II veterans, began a 12-week course in surgery at
the University of Minnesota on April 8.

Dr. A. V. Stoesser, associate professor of pediatrics
at the University of Minnesota and chief of the pediatric
service, Minneapolis General Hospital, spoke on "Al-
lergy in Children” at the Pediatric Postgraduate Con-
ference held April 15-20 at the University of Texas
School of Medicine, Galveston.

The 27th annual meeting of the Tuberculosis and
Health Association of St. Louis County was held in
Duluth April 16. Dr. Hilbert Mark of Minneapolis
was guest speaker. Paul H. Van Hoven of Duluth was
named president, Dr. William King, Eveleth, secretary,
and Dr. Mario Fischer, treasurer.

Dr. A. M. Mulligan has resumed practice in Brain-
erd after five years in the Army. He will have offices
with Dr. M. P. Gerber.

The house of delegates of the Minnesota State Med-
ical Association will act on the proposed state-wide pre-
paid medical care plan May 20, according to Rufus R.
Rosell, secretary. At the meeting of the association in
St. Paul, May 20-22, the planning and building of
hospitals for future needs will receive attention. Dr.
Viktor O. Wilson of the University of Minnesota is
scheduled to report on the state-wide hospital survey.

The 16th annual meeting of the Southern Society of
Clinical Surgeons was held at Rochester, April 16—18.
The group visited the University Hospital, Minneapolis,
April 19.

The northern border community of Karlstad, which
is taking heroic measures to attract a resident physician,
has encountered difficulties in building a hospital and
has postponed construction. However, Karlstad now
offers to remodel an eight-room house, with office and
a small hospital ward in addition to living quarters, to
suit the convenience of the doctor accepting the position.

Dr. F. C. Anderson of Cloquet will take over the
practice of Dr. Paul Swedenburg in Little Falls. He
will be associated with Drs. R. V. Fait and Douglas L.
Johnson.

The 1947 convention of the Central District Associa-
tion of the American Association for Health, Physical
Education, and Recreation will be held in Minneapolis.

Dr. Myron M. Weaver, assistant dean of the Uni-
versity of Minnesota Medical School, addressed the
Women’s Auxiliary of the St. Louis County Medical
Society May 7 on "Medical Practice in the Changing
Social Order.”

Dr. Roy Diessner of Waconia, until recently a major
in the Army Medical Corps, has reported to the Mayo
Clinic to take up a three-year scholarship in internal
medicine.

Dr. Arch H. Logan, staff member of the Mayo Clinic
for more than 35 years, has retired from active practice.

Dr. Earl Wood, physician at the Mayo Foundation,
will go to Europe in the company of another Foundation
physician to make a study of scientific laboratories in
Germany, Switzerland, Holland, and England, and to
do research for the Army Air Corps.

Dr. John J. Bittner of the University of Minnesota
has been elected vice president of the American Associa-
tion for Cancer Research.

NEWS FROM MONTANA

The Journal Lancet is in receipt of an attractive
booklet honoring Dr. W. F. Cogswell and commemor-
ating his 33 years of distinguished service as executive
secretary of the Montana State Board of Health. The
dedication reads in part: "In the history of Montana
and the Northwest there are many stories of pioneers.
Most of these were pioneers of the land, but a few were
pioneers in science and medicine. Dr. Cogswell was one
of these. His great foresight was a driving factor in
overcoming the prejudice against establishing a labora-
tory in the Bitter Root Valley to find the true nature
of Rocky Mountain Spotted Fever and to contribute to
its prevention and cure.”

Dr. C. E. Anderson writes from his office in the Med-
ical Arts Building in Great Falls to correct a news item
in our March issue. Far from retiring, Dr. Anderson
remarks, he is busier than ever, and has recently taken
an associate, Dr. James J. Bulger, a graduate of Mc-
Gill University School of Medicine who was discharged
from the Army as a captain early this year after three
years of service.

176

The Journal Lancet

Dr. J. W. Garberson of Miles City has been elected
president of the Montana State Board of Medical Ex-
aminers, succeeding Dr. C. H. Nelson of Billings. Dr.
P. E. Kane, Butte, was elected vice president, and Dr.
Otto Klein of Helena was re-elected secretary.

A new clinic has been formed in Havre, in which Drs.
Charles Houtz, Chester Lawson, D. S. MacKenzie, Jr.,
and David Almas are associated.

Dr. Joseph H. Brancamp has been appointed physi-
cian for the Butte Aerie No. 11, Fraternal Order of
Eagles.

Dr. Robert F. Miller has opened an office in Colum-
bia Falls, which had been without a resident physician
for several months.

Dr. F. M. Knierim has resumed his eye, ear, nose,
and throat practice in Glasgow.

Awards of merit for professional services contributed
to the selective service program have been awarded in
Helena to Drs. A. R. Foss, A. T. Haas, and L. W.
Brewer of Missoula and Drs. B. A. Place and B. L.
Pampel of the State Hospital at Warm Springs. The
awards were presented by Governor Sam C. Ford.

NEWS FROM NORTH DAKOTA

A clinic for crippled children was held April 15 at
Williston, with Dr. R. E. Dyson, pediatrician, Dr. J. C.
Swanson, orthopedic surgeon, and Beatrice L. Fugina,
physiotherapist, in attendance. The same group was in
charge of a clinic held at Mandan on April 13. The
annual orthopedic clinic for crippled children sponsored
by the Elks Lodge and the Public Welfare Board was
held at Dickinson May 4, with Dr. H. J. Fortin, ortho-
pedic surgeon, Dr. B. A. Mazur, pediatrician, and
Marie Bohnsack, physiotherapist, in attendance. These
clinics are part of a series of ten being held in the state
from April 13 to June 1.

The Fargo Public Health Laboratory has been moved
to a new location at 6 Roberts Street. Dr. E. M. Wat-
son, city health officer, supervises the laboratory, which
is in direct charge of Geraldine Clarey, medical tech-
nician, with James G. Coe as sanitarian. The laboratory
tests milk and water for counties in the southeastern
part of the state as well as for the city of Fargo.

The new North Dakota physicians’ service has en-
rolled several hundred members since its inauguration
March 4, according to Donald E. Eagles, executive
director.

Dr. E. A. Canterbury addressed St. Michael’s alumnae
nurses at Grand Forks in March on techniques and con-
ditions in Army hospitals overseas.

Drs. C. G. Johnson and Ted Keller of Rugby, both
veterans, have been appointed by the Veterans Adminis-
tration to give medical care to veterans in their com-
munity.

Dr. A. C. Orr of Bismarck has been appointed health
officer for Burleigh County. He was formerly director
of the state division of maternal and child hygiene.

Dr. Howard S. Cowley of Devils Lake, recently re-
turned from Army service, has gone to Louisville, Ken-
tucky, to study neurosurgery with Dr. R. Glen Spurling.

The proposed medical center at the University of
North Dakota was discussed at a meeting held in Grand
Forks on March 23. Dr. John H. Moore outlined the
benefits of the center in relation to state-wide medicine,
and John A. Page, director of the center, discussed aims,
probable costs, and facilities.

Dr. M. W. Garrison has resumed practice in Minot
following 3 years with the Army Medical Corps, in
which he held the rank of major.

J. Herbert Schriver, formerly of St. Cloud, Minne-
sota, has taken the post of X-ray technician at St. John’s
Hospital, Fargo, following 4J4 years with Navy hos-
pitals, chiefly in X-ray work.

NEWS FROM SOUTH DAKOTA

The Yankton District Medical Society met at Ver-
million April 23 with about 40 present. Dr. Richard L.
Egan of Creighton University School of Medicine spoke
on "Thiouracil in the Management of Hyperthyroid-
ism,” and Professor Orin M. Lofthus of the School of
Medicine at Vermillion on "Consideration of the Rh
Factor and Its Relation to Erythroblastosis,” with dis-
cussion by Dr. R. H. McBride of Sioux City, Iowa.
Dr. William Duncan of Webster, president of the
South Dakota State Medical Association, was a guest.
Dr. E. J. Abts and Dr. C. B. McVay, both of Yankton,
are new members.

Dr. Otto N. Raths, Jr., formerly of St. Paul, has
begun practice in association with his father-in-law, Dr.
F. C. De Vail, at the De Vail Hospital in Garretson.
He served three years with the Army Medical Corps.

The Commercial Club of Tripp is endeavoring to
secure a physician for the community.

Dr. Joseph Smith, recently discharged from the Army
after service in both the European and Asiatic theaters,
has come with his family from Indianapolis to Hot
Springs to become chief of the neuropsychiatric service
of the Battle Mountain Veterans Facility.

Dr. G. B. Sundquist, son of Mr. and Mrs. J. A.
Sundquist of Mitchell, has completed his internship at
Milwaukee County General Hospital, and has been com-
missioned a first lieutenant in the Army Medical Corps.

Dr. James L. Ryan, formerly of Sleepy Eye, Minne-
sota, and Dr. Mark Graeber of Aberdeen have located
in Eureka. Dr. Roy Christie, who has practiced in
Eureka since 1940, will locate somewhere in the Lake
Michigan area.

St. Mary’s Hospital, Pierre, has raised nearly enough
funds by voluntary contribution to finance the purchase
of an electrocardiograph.

Plans are completed to open the hospital at Philip as
soon as necessary repairs have been made and a physi-
cian is found to locate there, according to Ernest Clem-
ents, new president of the hospital association.

Dr. O. S. Randall, executive director of the South
Dakota Field Army of the American Cancer Society,
has appointed Dr. W. F. Bollinger of Parkston, Dr.
George E. Burman of Carthage, Dr. E. H. Grove of
Arlington, Dr. C. E. Kemper of Viborg, and Dr. C. H.
Delaney of Canton as educational directors to work with
their county commanders of the Field Army.

hen patients are given Cal-C-Tose, the physician is
assured of their cooperation because they actually enjoy taking vitamins in this
palatable form. Either hot or cold, Cal-C-Tose makes a tempting beverage whose
delicious chocolate flavor carries no suggestion of medication. Cal-C-Tose supplies gen-
erous amounts of vitamins A, Bi, B2, C, and D, and dibasic calcium phosphate in a form
acceptable even to fastidious patients. Available in 12-oz and 5-lb containers. . . .
HOFFMANN-LA ROCHE, INC. - ROCHE PARK - NUTLEY 10, NEW JERSEY

THE PLEASANT WAY TO TAKE VITAMINS

Ctas^Ud AductlU&nchts

ASSOCIATES WANTED

Thirty-four year old physician, with two years of gen-
eral practice and over four years service, desires associa-
tion with one or two doctors doing surgery. Licensed in
North Dakota. Address Box 840, in care of this office.

PRACTICE FOR SALE

North Dakota physician retiring after 39 years in same
town wishes to sell practice and office equipment. Only
physician in presently booming town of 1350 located on
main line of Northern Pacific. Extensive territory, good
roads. Home suitable for office and residence also for
sale. Address Box 838, care of this office.

ASSISTANCE AVAILABLE

Aznoe’s, established in 1896, has available a number
of well trained physicians (diplomates of the specialty
boards, industrial physicians and surgeons, general prac-
titioners, psychiatrists, tuberculosis specialists and resi-
dents). For histories write Ann Woodward, Aznoe’s-
Woodward Medical Personnel Bureau, 30 North Michi-
gan Ave., Chicago 2, Illinois.

LABORATORY TECHNICIAN WANTED

Wanted: A laboratory technician, preferably regis-

tered, to be an assistant in our general laboratory which
serves twelve doctors in the Clinic. The position may be
regarded as permanent. The pay will be satisfactorily
arranged. Write Dakota Clinic, 702 First Avenue South,
Fargo, North Dakota.

PHYSICIAN WANTED

Physician for first-aid dispensary, John Morrell 6c Co.
Contact Dr. S. A. Donahoe, Sioux Falls, South Dakota.

Doctor wanted to fill in as attending physician to
special hospital in Minneapolis. Recent graduate. Dis-
charged serviceman or other. Available six months or
longer. Must have Minnesota registration. Good salary.
Address Box 841, care of Journal Lancet.

Adu€\tis€As' AtoHOUHCWvvVhts

PEDIATRIC ANTIQUES ON TOUR

It has been well said that more progress has been made in
pediatrics during the past three or four decades than in all pre-
vious time. As applied to the feeding part of pediatrics, the
Mead Johnson Collection of Pediatric Antiques bears eloquent
witness to the great strides made. Without such evidence, it
would be difficult to imagine our own grandparents being fed
from some of these odd-shaped utensils that defied thorough
cleansing. To be sure, sterilization and pasteurization were not
then in vogue. Not all babies received breast milk in abundance.
In the days when wet nurses were common, some of these en-
terprising women literally did a wholesale business, managing
to nurse three or four infants.

The baby’s cereal of a century ago was simply stale bread
lightly boiled in water, wine, or beer. Butter or sugar might be
added, but the use of milk was regarded as fraught with dan-
ger. It was thought, according to Dr. T. G. H. Drake, that
"Milk might bring on the watery gripes, or the infant might
imbibe with the milk the evil passions and frisky habits of the
animal supplying the milk.”

The collection has been growing in size and scope and is
of increasing interest for teaching purposes. The destruction of
original sources during the war tends to add to the value of
these objects. The collection now goes on an annual pilgrimage
to colleges, hospitals, museums, libraries, and other institutions
of learning. Arrangements may be made for "stopovers” upon
application to the curator, Mead Johnson & Company, Evans-
ville 21, Indiana.

(38,400 grains fishing tackle,
50,000 grains sporting togs.
Blend with lake and sunshine.
Take frequently throughout
the summer and fall.)

If you have a prescription like this to fill — better drop
in and see us. We don’t supply the lake or the sunshine, but the other
ingredients we have in number and quality. Our new supply of summer
and fall sporting goods has just arrived. We would appreciate an
opportunity to show it to you.

JOHNSON -GOKEY SHOP

Special Sporting Equipment

525 Second Avenue South

Minneapolis, Minn.

GREATER RAPIDITY
OF

CLINICAL RESPONSE

MOL-IRON
FeS04

TREATMENT DAYS

Completely effective therapeutic response (return to normal blood values)
was obtained in an average of 13.7 days of Mol-lron therapy — whereas
ferrous sulfate therapy failed to produce normal hemoglobin values even
after an average of 20.3 days.

GREATER AVERAGE
DAILY

HEMOGLOBIN INCREASE

IIIHIHI

mmm

GRAMS PER CENT

0.36 Gm. % MOL-IRON
FeS04

Note that the group treated with Mol-lron averaged a daily hemoglobin
increase markedly greater than the increase achieved with ferrous sulfate.

MUCH LOWER
AVERAGE
INTAKE OF IRON

3-5 Gm. MOL-IRON

7.87 Gm. CoCd

GRAMS redU4

The group treated with ferrous sulfate ingested 100% more bivalent iron

than the Mol-lron treated group — yet in the Mol-lron group a return to normal
blood values was achieved whereas optimal response in the ferrous sulfate
treated group was not accomplished in the period of study.

WHITE

LABORATORIES, INC.

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observed in treatment of iron-deficiency anemias with
White’s Mol-lron.

Dosage; 1 or 2 tablets 3 times daily after meals.

Bottles of 100 and 1000 tablets.

Ethically promoted — not advertised to the laity.

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IRON-DEFICIENCY ANEMIAS

White’s Mol-lron is a specially processed
co-precipitated complex of molybdenum
oxide 3 mg. (1/20 gr.) and ferrous
sulfate 195 mg. (3 gr.). Available clinical
evidence indicates that it is not only toler-
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sulfate, but also that its use provides the
striking advantages charted below :

FAMOUS SWISS SCIENTISTS VISIT
HOFFMANN-LA ROCHE

Dr. Leopold Ruzicka, winner of the 1939 Nobel Prize in
Chemistry, and Dr. Tadeus Reichstein, the first man to syn-
thesize vitamin C, who are here to study American scientific
developments, recently visited the Roche Research Laboratories
of Hoffmann La Roche, Inc., pharmaceutical manufacturers of
Nutley, N. J. Drs. Ruzicka and Reichstein will visit other
leading research institutions and lecture before many scientific
groups during their six to eight weeks’ stay in the United
States.

These two famous Swiss scientists are here at the invitation
of the American-Swiss Foundation for Scientific Exchange — an
organization founded to tie together again the scientific bonds
of the two countries, severed during the war years, by fostering
visits of scientists of one country to the other. The American
Cancer Society also participated in the invitation to Drs.
Ruzicka and Reichstein to visit our country because of their
extensive knowledge of steroids — organic chemical substances
which may play an important role in solving some of the mys-
teries of cancer.

NEW SAFER MEDICATION WITH
SULFONAMIDES

The dangers of toxic reactions to the kidneys and crystal
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sulfadiazine is administered, has been greatly reduced by the
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Proven by clinical trial, this means that the incidence of kid-
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sulfathiazole therapy is often higher with the combination.

Combinations of sulfathiazole and sulfadiazine, known as
Combisul-TD are now produced by the Schering Corporation
of Bloomfield, N. J. For the safer treatment of meningitis,
Combisul-DM, a combination of sulfadiazine and sulfamerazine
is likewise available.

DISTRIBUTORS OF DIASPORALS

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Perforation of Choledochus Cyst with
Biliary Peritonitis

Report of a Case Submitted to a Three^Stage Operation

H. M. Blegen, M.D., F.A.C.S.
and

Esther L. Boyer, Ph.D., M.D.

Missoula, Montana

Congenital cystic dilation of the common duct,
otherwise known as choledochus cyst or diverticu-
lum of the common duct, is a rare but interesting
anomaly. Shallow, Eger, and Wagner A in a compre-
hensive review of the literature were able to find only
175 cases reported prior to 1943.

Etiology

Although the etiology is as yet obscure, the condition
is thought to result from a congenital weakness in the
wall of the duct. Hutchins and Mansdorfer 2 point
out the similarity between this condition and congenital
hypertrophic pyloric stenosis. The localized nature of
the dilation differentiates it from the diffuse dilation
associated with common duct obstructions. In the ma-
jority of cases the distal end of the duct is normal,
although in a few cases angulation, kinking, and stenosis
have been described.

Pathology

The cyst forms a retroperitoneal mass in the right
upper quadrant of the abdomen below the liver, displac-
ing the duodenum and pancreas anteriorly, the colon
inferiorly, and the gallbladder laterally. The size of the
mass may vary from that of a walnut to that of a full-
term pregnant uterus, containing as much as eight liters

The authors are indebted to Dr. A. R. Kintner and Dr.
R. D. Weber for consultation and advice during the treatment
of this case, and also to Mr. Bernard Hoffman of Montana
State University, who prepared the illustrations.

of biliary fluid. This fluid may be clear, white, or pur-
ulent, depending on the degree of stasis and infection.
The wall of the cyst is thickened and composed of a
tough, dense, fibrous connective tissue with no epithelial
lining. It is covered with a vascular retroperitoneal con-
nective tissue. Usually the gallbladder and the upper
end of the common duct are normal in size, or only
slightly dilated. Three openings are found within the
cystic cavity: the entrance of the common duct above,
the lower end of the common duct below, and the cystic
duct on the right. Occasionally the hepatic ducts may
enter the upper pole separately.

Symptoms

The signs and symptoms are usually minimal until
the second or third decade of life. Of the reported cases,
three fourths were under 25 years of age and four fifths
were female. Pain was present in 59 per cent of the
cases, jaundice in 70 per cent, and a palpable abdominal
mass in 77 per cent. When this triad occurs in a young
female a careful diagnosis should be made. Fever was
absent in the majority of cases, but when present was
a sign of infection within the cyst, hepatitis, cholangitis,
or overlying peritonitis. In advanced cases the liver be-
comes cirrhotic, with associated ascites and splenomegalia.

Treatment

Unless the anomaly is corrected by surgery almost
all these individuals eventually die of biliary obstruction,
infection, or their sequelae. In the reported cases the

177

178

The Journal Lancet

mortality was 5 1 per cent. It is interesting to note that
in those with the correct preoperative diagnosis the mor-
tality was 30 per cent, in contrast to 62 per cent for
those in which the true nature of the anomaly was not
suspected. Table 1 summarizes the various surgical pro-
cedures performed in the 175 cases analyzed by Shallow,
Eger, and Wagner.

Table 1

Surgical Procedures in 175 Cases Analyzed by
Shallow, Eger, and Wagner

Operation Cases

Anastomosis without Resection of Cyst
Immediate anastomosis of cyst to

Deaths

Mortality
(Per Cent)

gastrointestinal tract

(one case also had gastroenterostomy
and enteroenterostomy)
Immediate anastomosis of gallbladder

to gastrointestinal tract

Elastic drain tube between cyst and

duodenum

Drainage of cyst followed by secondary
anastomosis of cyst to gastrointes-

100

tinal tract

A nastomosis and Resection of Cyst

Cyst excised with primary anastomosis .

Cyst excised with secondary anastomosis
Excision of cyst with drainage,

no anastomosis

Partial excision of cyst wall
Miscellaneous

Aspiration

Drainage of cyst, with or without

100

cholecystectomy ...

Marsupialization

100

Other procedures

No surgical treatment

Total

175

Aspiration, marsupialization, and simple drainage of
the cyst are mentioned, only to be condemned. These
procedures all carried a prohibitive mortality and were
usually performed when the true nature of the anomaly
was not suspected.

Best results were obtained by primary anastomosis of
the cyst or gallbladder to the gastrointestinal tract. The
only objection to this procedure is the presence of the
dilated duct, which acts as a reservoir for infected bile
and regurgitated intestinal material, with an ever-present
danger of ascending biliary infection. Swartley 4 min-
imizes this danger and offers evidence to show that after
anastomosis the cyst will decrease considerably in size.

The best procedure physiologically is one in which the
cyst is excised and the upper end of the common duct
anastomosed to the gastrointestinal tract. In the eight
cases in which this operation was accomplished the mor-
tality was 37 per cent. In view of the recent advances
in the surgical technique of anastomosis between the
biliary system and the gastrointestinal tract, as developed
in the treatment of common duct strictures and in car-
cinoma of the head of the pancreas, there is reason to
believe that such radical operations will be done in future
with increasing frequency, with reasonable mortality and
a decrease in morbidity.

Statistics indicate that in uncomplicated cases a one-
stage operation is preferable. Multiple-stage procedures
are reserved for cases in which complications have oc-
curred or in which the operative risk is great. Multiple-
stage operations usually consist of preliminary external
drainage of the biliary tract, followed by secondary
anastomosis performed at a later date. The mortality is
high because of the increased technical difficulties in per-
forming the anastomosis and also because of the diffi-
culty in maintaining adequate nutrition in the presence
of prolonged external drainage of bile.

The following case is of interest because spontaneous
perforation of the cyst occurred, with generalized peri-
tonitis which localized to form a huge right-sided biliary
abscess. After drainage of the abscess an unsuccessful
attempt was made to correct the anomaly by two-stage
operation; this operation may be of value in treating
certain selected cases where an immediate one-stage pro-
cedure is not feasible. The first stage consisted of ex-
ternal drainage of the hepatic duct with a T tube, par-
tial excision of the cyst, and the utilization of the gall-
bladder in the formation of an external biliary fistula.
The final stage consisted of an anastomosis between the
gallbladder and the duodenum.

Report of a Case

The patient, a 17-year-old girl, had always been in
excellent health before her present illness. Her past his-
tory was negative, except that in 1928, when she was
2 years old, her parents were informed by their family
physician that the child had an enlarged liver. She first
became ill on or about February 18, 1945, with mild
abdominal cramps, nausea, and vomiting, followed by
a slowly progressive jaundice. After the first two days
of the illness she had no appreciable pain. The stools
were clay colored and the urine dark. She had an inter-
mittent fever ranging from 100° to 102°. A mass palp-
able in the right upper quadrant of the abdomen was
thought to be an enlarged liver. Her parents had both
had gastroenteritis the preceding week, and there had
been several cases of catarrhal jaundice in the com-
munity. A diagnosis of catarrhal jaundice or infectious
hepatitis was made and therapy was instituted.

After admission to the hospital on March 6 she grad-
ually improved. Her temperature gradually dropped,
ranging from 99° to 100°. Her serum bilirubin dropped
from 21 to 16 mg., and the mass in the right upper
abdomen was said to decrease somewhat in size. Between
March 20 and March 27 she became progressively worse.
Her temperature rose steadily to 105°, with a pulse of
140. She developed increasing abdominal pain, with
marked abdominal distention and increased jaundice.

Physical examination on March 27 revealed her to be
critically ill, with a temperature of 105°, pulse 140, and
respiration 24. The skin was jaundiced 3 plus. The
pupils were equal and reacted to light and accommoda-
tion. The tonsils had been removed. The teeth were in
good condition. Examination of the neck and extremi-
ties was essentially negative. The lung fields were clear
and the heart was essentially negative except for tachy-
cardia. The abdomen was much distended, with shifting
dullness in the flanks and tympani in the midportion

June, 1946

179

60. Hoffman 'i?

Fig. 1. Diagram of choledochus cyst: a, cyst; b, gallbladder (actually the cystic duct

was of normal size, but it entered the cyst at this point) ; c, liver; d, e, hepatic ducts;
f, T tube; g, stomach; h, duodenum. P, perforation.

anteriorly. There was generalized tenderness, hut very
little rigidity. A sensation of fullness was present in the
right upper abdomen, but because of distention no defi-
nite mass could be outlined. Rectal examination was
essentially negative, except for a soft fullness related to
the abdominal distention.

The red blood count was 3,330,000, hemoglobin 62
per cent, and white blood count 22,400 with 88 per cent
PMNs. The serum bilirubin was 25 mg., with an im-
mediate direct van den Bergh reaction. Blood urea was
38 mg. Sedimentation rate was 113 mm. in one hour.
The prothrombin time was reported as 105 per cent, the
bleeding time 2 minutes, and clotting time 3 minutes.
(She had had several transfusions and large doses of
vitamin K.) There was a false positive Kahn reaction,
but a negative Wassermann and Mazzini. The urinaly-
sis was essentially negative, except for a 3 plus reaction
for bilirubin. There was an absence of bile in the stool.
Serum protein was 6.2 gm. Flat plate of the abdomen
revealed a small amount of gas in the colon. There was
no evidence of distended small bowel. There was a dif-
fuse opacity that resembled intraperitoneal fluid.

Diagnostic paracentesis was performed and 1700 cc.
of dark-green thick bile were obtained. After release
of this fluid the abdomen became soft and scaphoid.
A smooth mass could be palpated in the right upper
quadrant of the abdomen, extending four fingers below
the costal margin. The mass did not move with respira-
tion. At this time it was felt that the patient probably
had a ruptured gallbladder as the result of some form
of common duct obstruction. Because of her critical

condition and the relief obtained from paracentesis,
laparotomy was deferred.

In the period between March 27 and April 17 she
gradually improved. Her temperature continued to range
from 101° to 104° and her pulse from 120 to 140. Her
serum bilirubin dropped to 4.2 mg. Paracentesis was
performed every three or four days; 3000 to 3500 cc.
of bile were removed on each occasion. On three occa-
sions cultures of this fluid were all reported negative.
After paracentesis the abdomen would become scaphoid,
but it would gradually refill in about three days. The
peritonitis gradually walled off to form a huge right-
sided abscess, extending from the diaphragm to the
pelvis. Peristaltic activity became evident in the bowel,
which was displaced to the left. On April 13 a catheter
was placed in the abscess cavity through the paracentesis
wound in the right lower quadrant, and by means of
Wangensteen suction continuous biliary drainage was
maintained.

First Operation (April 17) . Incision and drainage of
biliary abscess. The operation was performed in the pa-
tient’s room under local anesthesia. The abscess cavity
was entered through a right subcostal incision 3 inches
long. The liver could be felt above and a large cavity
below, extending down toward the pelvis. In order to
obtain more adequate drainage a second right McBurney
incision was made in the right lower quadrant. Over
3000 cc. of biliary fluid were obtained by suction. Pen-
rose drains were placed through both incisions.

Following the operation the patient did fairly well
for three days, during which time her temperature

180

The Journal Lancet

P (rJjgffjTVflll 'If

Fig. 2. External drainage of hepatic ducts with T tube, using gallbladder to form an
external biliary fistula: a, remnant of cyst, most of which has been resected; b, T tube;

c, gallbladder; e, f, hepatic ducts; g, T tube.

dropped gradually by lysis. However, on the fourth post-
operative day (April 21) she developed pneumonia in
the lower left lung field, followed in two days by a
pleural effusion. This gradually subsided after multiple
thoracentesis and supportive treatment with penicillin
and sulfadiazine. Her abdomen remained soft. The
abscess continued to drain bile. The stools remained
acholic. Although she was still a poor risk for major sur-
gery, it was apparent that she could not survive unless
external drainage of the biliary tract was accomplished
to sidetrack the bile from the abscess cavity. The pre-
operative diagnosis was still not clear in our minds,
although choledochus cyst was considered among several
other possibilities.

Second Operation (June 30, Figs. 1 and 2). Abdom-
inal exploration, partial excision of the cyst, external
drainage of the common and hepatic ducts, and anasto-
mosis of the ampulla of the gallbladder to the upper
end of the common duct. General gas ether anesthesia.
Right rectus upper abdominal incision medial to the right
subcostal wound.

On opening the peritoneal cavity numerous flimsy,
friable adhesions were encountered. These were most
marked on the right side of the abdomen and formed
a protective wall over the site of the right-sided abscess.
A large mass 8 inches in diameter was found below the
liver (Fig. 2). The mass was typical of choledochus
cysts. The duodenum was displaced forward and to the
left, as was the head of the pancreas. A normal-sized
gallbladder was seen displaced to the right. The colon

and omentum were loosely adherent over the cyst and
gallbladder.

In separating these adhesions we inadvertently entered
the old abscess cavity in the right upper abdomen. On
compressing the cyst we could then see bile escape from
the point of perforation located on the upper lateral
margin of the cyst below the liver. (It later proved
to be between the entrance of the cystic duct and the
entrance of the upper end of the common duct.) Be-
cause of the danger of injuring vital structures by com-
plete external mobilization, the cyst was opened widely
so that its internal openings could be identified. The
opening of the common duct measured 1 V2 cm. in diam-
eter and was readily located at the upper pole of the
cyst. The junction of the hepatic ducts was I/2 cm.
above this point. By passing a probe through the gall-
bladder the opening of the cystic duct was identified
on the right lateral wall about 2 inches from the com-
mon duct. The perforation was located between these
two points and was about 5 mm. in diameter. The open-
ing of the distal end of the common duct was pinpoint
in size, admitting a very fine probe. Its course could
be followed through the thinned-out pancreas, but the
tract was very stenotic and atrophic. No stones were
palpated.

Because of the perforation and the existing infection
primary anastomosis seemed inadvisable. Instead, plans
were made to drain the hepatic ducts in a manner that
would sidetrack the flow of bile from the cyst and abscess
cavity (Fig. 3). Working from inside the cyst, we made

June, 1946

181

fo.Cr- Hoffman

Fig. 3. Anastomosis of gallbladder to the duodenum over the T tube: a, duodenum;
b, gallbladder; d, e, hepatic ducts; g, T tube. G, gastrotomy.

an incision around the internal opening of the upper end
of the common duct, freeing this structure from the
cyst. In this maneuver a line of cleavage was found,
and although it was not our original intention, four
fifths of the cyst wall peeled out with great ease. The
adherent portion below the duodenum and pancreas was
not disturbed. The cystic duct was divided near the cyst
without injury to the cystic artery. A T tube was then
placed in the end of the common duct with one arm
in each hepatic radical. The limb of the T tube was
then brought out through the gallbladder and the am-
pulla of this structure was sutured with silk to the end
of the common duct. This formed an external fistulous
tract made up of biliary structures, namely, the hepatic
duct, the upper end of common duct, and the gall-
bladder. The T tube was brought out through the
abdominal wall lateral to the incision and the fundus
of the gallbladder was pulled snugly against the parietal
peritoneum. Several Penrose drains were left against
the remaining retroduodenal portion of the cyst wall and
the abdomen was closed in layers. The patient’s condi-
tion was critical, but we thought if she could survive the
immediate operative shock our operative procedure was
so arranged that at a later time the gallbladder could
be anastomosed to the gastrointestinal tract.

Following the operation the patient did surprisingly
well. She soon regained consciousness. Although her
temperature was high (103°-104°) for three days, her
physical and mental state seemed good. The fever grad-
ually subsided by lysis and was normal after the tenth
postoperative day. Nasogastric suction was discontinued
on the sixth postoperative day, when she began taking

fluids and food by mouth. The T tube drained from
300 to 600 cc. of bile a day, with some drainage around
the tube. Our greatest difficulty was to replace the lost
bile. This was done by giving desiccated bile salts by
mouth and by replacing the bile with a nasogastric tube.
Because of the patient’s progressive weight loss, in spite
of extensive supportive treatment with parenteral admin-
istration of fluids, proteins, blood plasma, and vitamins,
we felt it necessary to go ahead with the third stage
and attempt to anastomose the biliary tract to the intes-
tine, even though we should have preferred waiting
longer.

Third Operation (July 26) . Cholecystoduodenostomy.
(Fig. 3.) Right rectus incision through the old scar. The
adhesions were separated. The gallbladder was identified
and freed from the abdominal wall. After resecting a
small portion of the fundus an anastomosis was per-
formed between the cut end of the gallbladder and the
duodenum in a manner similar to that described by
Shallow, Eger, and Wagner. A curved hemostat was
inserted through a small prepyloric gastrostomy and
passed into the duodenum. At the site of the anastomo-
sis the end of the hemostat was forced through the duo-
denal wall. The end of the T tube was grasped and
pulled into the stomach. The gallbladder was then
sutured snugly to the duodenum around the tube with
interrupted silk sutures. The T tube was left in place
because of the danger of obstruction. Penrose drains
were placed at the site of the anastomosis and the ab-
domen was closed in layers.

The immediate postoperative course was very satisfac-
tory. For two days she had a sharp, febrile reaction

182

(T 103°— 104° R), which gradually subsided by lysis and
remained between 100° and 101 R after the tenth post-
operative day. She gradually improved. Drainage from
the nasogastric tube revealed that bile was draining into
the stomach. However, there was some bile-stained
drainage on the dressing also. Her abdomen remained
soft and scaphoid and normal peristaltic activity began.
There was a slight icteric tint to the sclera on the second
postoperative day, but it disappeared by the fifth post-
operative day. On the seventh postoperative day she
began taking fluids by mouth and the nasogastric tube
was clamped at intervals. On the ninth day an abundant
watery, bile-stained drainage appeared on the dressing,
and it was obvious that a duodenal fistula was present.
On close observation it was estimated that 50 per cent
of all oral fluids was lost through the fistula. Continuous
suction was then instituted by the nasogastric tube, as
well as by a catheter inserted in the drainage wound.

In spite of her marked emaciation her condition was
fairly good and her mental attitude excellent. We felt
if we could maintain an adequate intake of fluids, nour-
ishment, and vitamins, supported by transfusions of
blood and plasma and the replacement of lost bile, she
might still recover. In order to do this and still maintain
gastric and duodenal suction, a jejunostomy was felt
necessary. At 5:30 p.m. on the evening of the eighteenth
postoperative day this plan was explained to the patient,
who accepted the prospect of another operation cheer-
fully.

Thirty minutes later she suddenly complained of short-
ness of breath and substernal pain. She gasped and in a
few seconds died, undoubtedly as a result of a pulmo-
nary embolus. Contributing factors to the development
of thrombosis were undoubtedly the large doses of vita-
min K, the multiple transfusions of blood, plasma and
other intravenous fluids, the massive doses of penicillin,
and the superficial thrombophlebitis resulting from in-
dwelling intravenous cannulae after all three operations.

Unfortunately, autopsy was not performed. During
the period of time in which permission was being ob-
tained the body was inadvertently removed by the local
undertaker, who was well on his way to the home town,
130 miles away, by the time we discovered the fact.

Discussion

As far as we can determine, this is the fourth case
to be recorded in which perforation or rupture of the
cyst occurred. Wright,1’ in reporting in 1935 a case diag-
nosed by X-ray examination, casually referred to another
case in which the patient died from rupture of a chole-
dochus cyst after a fall from a bicycle.

Blocker, Williams, and Williams 1 reported in 1937
the case of a 14-year-old boy admitted to the hospital
15 minutes after falling from a swing. Exploration
revealed bile-stained fluid in the peritoneal cavity, with
retroperitoneal extravasation of blood and bile in the
region of the duodenum. Because of the grave condi-
tion of the patient the area was drained and the abdo-
men closed. Death came the following day. Autopsy
revealed a congenital cyst of the common duct which
measured 5x7x7 cm. A linear rupture measuring 4 cm.
in length was found on left inferior portion of cyst with

The Journal Lancet

considerable extravasated bile and blood in the retro-
peritoneal space.

Walton,1’ reporting six cases (the largest number re-
ported by a single author) , describes the case of a baby
girl admitted to the hospital at the age of one month.
She had been ill two weeks with progressive jaundice.
Her condition became steadily worse and she died five
days later. Autopsy revealed a congenital cyst of the
common duct with a small perforation on the right
lateral surface. The peritoneal cavity contained blood
and bile, with evidence of generalized peritonitis.

In all these cases the patient died shortly after perfora-
tion occurred. Only one was submitted to surgery, but
because of the critical condition of the patient the abdo-
men was closed after drainage only. Our case lived five
months after perforation and then died unexpectedly
of a pulmonary embolus. The biliary peritonitis was
treated at first by multiple paracentesis, during which
time localization and abscess formation occurred. In
spite of her critical condition and the grave surgical risk
she survived two major operations and finally died
eighteen days after the third operation.

The greatest difficulty in this case was the problem
of replacing lost bile and maintaining adequate nutrition
in spite of the extensive intravenous therapy with blood,
plasma, amino acids, and vitamins. Bile was replaced
through a nasogastric tube and by the oral administra-
tion of desiccated bile salts. Neither of these methods
was adequate. Our chances in this case undoubtedly
would have been better had we performed a jejunostomy
early in the disease to facilitate the administration of
fluids and food. The final anastomosis could then have
been deferred until the general condition of the patient
and the local character of the tissues had reached a
state more favorable to primary healing.

Summary and Conclusions

1. Congenital cystic dilation of the common duct
(choledochus cyst) is a rare anomaly, usually seen in
young females. The usual symptoms are abdominal pain,
jaundice, and a palpable upper abdominal mass. Unless
the anomaly is corrected by surgery these individuals
usually die of biliary obstruction or infection. The opera-
tion of choice at present is a one-stage anastomosis of
the cyst or gallbladder to the gastrointestinal tract. With
the recent developments of surgical technique in this
area there is reason to believe that excision of the cyst
will be attempted with increasing frequency, with a j
resultant decrease in morbidity. Although one-stage
operations are preferable, multiple procedures are some-
times necessary where complications have occurred.

2. A case is presented in which perforation of the cyst
occurred, with a resultant biliary peritonitis that localized
to form a huge right-sided biliary abscess. After incision
and drainage of the abscess an unsuccessful attempt was
made to correct the anomaly by a two-stage operation.
This operation may be of value in the treatment of
certain selected cases. The first stage consisted of ex-
cision of part of the cyst and the utilization of the gall-
bladder to form an external biliary fistula. In the second
stage the gallbladder and duodenum were anastomosed.

3. Special attention is called to the importance of a

June, 1946

183

complementary jejunostomy in the treatment of compli-
cations from congenital choledochus cyst when multiple-
stage operations are necessary. Had this been done in
the case presented the chances of recovery would have
been better.

4. As far as we can determine, only three other cases
of choledochus cyst complicated by rupture have been
previously reported in the literature. These cases are
reviewed briefly.

References

1. Blocker, T. G., Williams, Harriss, and Williams, J. E.:

Traumatic Rupture of Congenital Cyst of the Choledochus.
Arch. Surg., 34: 695-701, 1937.

2. Hutchins, Elliott H., and Mansdorfer, G. Bowers: Con-
genital Cystic Dilation of the Common Bile Duct with Se-
quelae. J A M. A., 125: 202-4 (May 20), 1944.

3. Shallow, Thomas A., Eger, Sherman A., and Wagner,
Frederick B.: Congenital Cystic Dilation of the Common Bile
Duct. Ann. Surg., 117: 355-85 (March), 1943.

4. Swartley, William B.: Choledochus Cyst; Final Report of
Two Cases. Ann. Surg., 118: 91—96 (July), 1943.

5. Walton, J.: Congenital Diverticulum of Common Bile

Duct. British J. Surg., 27: 295—315 (Oct.), 1939.

6. Wright, A. Dickson: As quoted by Shallow, Eger, and
Wagner.

A PREDICTION: NEW DRUGS WILL CONTROL VIRUS DISEASES

Dr. Selman A. Waksman, Professor of Microbiology at Rutgers University, and dis-
coverer of streptomycin, predicts that the time is not far off when such diseases as the com-
mon cold, infantile paralysis, and tuberculosis will be brought under practical control through
the enlargement of medical knowledge and the development of new drugs.

Speaking before a group of scientists, engineers, and educators at the George Westing-
house Centennial Forum, Dr. Waksman said that within a period of five years we have wit-
nessed the development of radically new methods of treating a variety of diseases in man and
animals. The possibilities are just being explored, and there is promise of greater things in
the future, notably in finding agents to combat many diseases, especially the virus diseases,
against most of which no effective agents are known at present.

Pointing the way to such knowledge are studies being made of the microscopic forms of
life that we commonly refer to as microbes, which can be seen only with the most powerful
microscopes, but whose activities have touched upon every phase of human endeavor. Some
microbes he classified as injurious to man and others as beneficial.

Not so very long ago man was at the complete mercy of the microbes. Pestilence and
epidemics have influenced history in far greater and more important ways than have battles.
The progress of man has often been changed or delayed by the harmful effects of microbes,
which may have caused the destruction of crops, with the resulting hunger and starvation
and outbreaks of epidemics, such as bubonic or black plague and cholera, which profoundly
affected historical events.

As late as the turn of the century more soldiers died from typhoid than from the weap-
ons of war. Now typhoid scarcely ever appears in our armed forces. During World War I
deaths from typhus, influenza, and gas gangrene and other wound infections greatly exceeded
the deaths caused in actual battle. Such scourges as malaria, pneumonia, and syphilis have
now been brought under practical control; their causes and effects are well understood and
excellent treatments for them are known.

Although many important diseases, such as influenza, the common cold, poliomyelitis,
rheumatic fever, tuberculosis, and undulant fever are still rampant, or may become so under
certain conditions, such as those following a long period of malnutrition or social maladjust-
ment in a postwar period, the time is not far off when these scourges, as well, will be brought
under practical control.

Chemotherapy, the treatment of diseases with chemical agents, beginning with the use
of salvarsan, the introduction of the sulfa drugs, and finally the application of antibiotics,
is on the threshold of a great epoch that will no doubt prove of the greatest usefulness in
combating diseases caused by microbes.

184

The Journal Lancet

Report of an Unusual Case of Mediastinal Tumor

S. G. dayman, M.D.

San Haven, North Dakota

The case here reported presents a multiplicity of severe
diseases, and is therefore reported in some detail.
The patient, a farmer, was a white male, 57 years of
age, married, and a native American of German extrac-
tion. He complained of cough of about three months’
duration and hoarseness of about ten months’ duration
before admission to the North Dakota State Tubercu-
losis Sanatorium on August 7, 1944. During the year
previous to admission he had lost about ten pounds in
weight.

His illness had begun about one year previously with
an attack of "flu”. Following this attack, which was
characterized by fever, chills, cough, and hoarseness, his
hoarseness persisted. He saw several local doctors, one
of whom insisted that he see a throat specialist, but he
did not follow this advice. About three months before
admission to the sanatorium he noted a cough, at first
dry and nonproductive, later productive of about two
drams of slimy sputum daily. Three months previous
to admission the patient was examined at a local clinic
and diagnosed as a case of pulmonary and laryngeal
tuberculosis, and admission to the sanatorium was rec-
ommended.

Upon admission he was described as a well-developed,
well-nourished, adult white male, who did not appear
acutely ill. Report on indirect examination of the larynx,
not detailed, described the true vocal cords as appearing
edematous and reddened.

Physical examination of the chest showed some dull-
ness in both apices posteriorly. There were a few fine dry
rales heard in the right apex and along the inner border
of the right scapula, after expiratory cough. On fluoros-
copy at this time it was noted that there was a circum-
scribed mass in the posterior mediastinum. Aneurysm
of the thoracic aorta was ruled out by careful fluoroscopy.
The sputum was positive for tubercle bacilli on concen-
trated examination, Gaffky II, on many specimens.

On September 22, 1944, direct laryngoscopy revealed
a marked edema of the arytenoid and interarytenoid
areas and of the entire posterior larynx and false cords.
No ulceration or granulation was seen. Edema, however,
was so marked as to make passage of the bronchoscope
through the larynx inadvisable, because of the danger
of increasing the edema, with resulting laryngeal obstruc-
tion. Accordingly, no attempt at bronchoscopy was
made. The post-laryngoscopic diagnosis was severe tuber-
culous laryngitis with marked edema.*

Chest X-rays revealed that the right lung was essen-
tially negative for pulmonary pathology, except for peri-
bronchial infiltration. The left lung showed a small
amount of mixed exudative and proliferative infiltration
at the level of the 2d and 3d ribs and 2d interspace
anteriorly. There was a rounded, sharply demarcated

*W. L. Walibank, M.D., performed this bronchoscopy.

mass in the hilar region, extending into the lung fields
from the mediastinum at the level of the 2d and 3d
ribs and interspaces anteriorly. The total diameter of
the mass was about 814 cm. by 9 cm.

At this time no conclusions were drawn, and diagnosis
was deferred. The differential diagnoses included: (I)

A solitary mediastinal cyst or tumor. (2) Mediastinal
lymph gland tumor of the lymphoma variety. (3) Pos-
sible benign tumor of the chest.

Further X-rays were taken, and oblique views seemed
to localize the mass in the lower midportion of the chest,
slightly anteriorly, probably in the region of the main
bronchi in this region. On November 17, 1944, there
was a rather sharp and definite increase in the size of
the circumscribed mass. At this rime it extended from
the hilar region into the lower midlung field on this
side. There was a very small but new area of infiltra-
tion in the extreme base, in the region of the cardio-
phrenic angle. Because of the patient’s positive sputum
for tuberculosis and severe tuberculous laryngitis, it was
now apparent that he demonstrated more than one
severe pulmonary disease at the same time. The mass
had all the appearance of a nontuberculous neoplasm.

On December 29, 1944, coincidental with a marked
downward clinical course characterized by increased tox-
icity, pain in the left chest and gastric region, nausea,
vomiting, and pain in the back, an X-ray revealed fur-
ther marked increase in the size of the rounded mass,
which now extended to the lateral chest wall and filled
the costophrenic angle.

Th ree days previously fluoroscopy had revealed the
entire left chest to be opaque, and chest aspiration was
performed. The first aspiration was productive of 1700
cc. of cloudy amber fluid. Six hours later a second aspi-
ration was done, and another 500 cc. of fluid were as-
pirated. Thereafter for eight consecutive days an aver-
age of 600 cc. of fluid were removed daily. The fluid
changed in character from cloudy amber to yellow, puru-
lent, putrid material. After the fifth aspiration 30,000
Oxford units of penicillin were injected intrapleurally.
This injection was repeated at each succeeding aspira-
tion. Laboratory examination of the fluid revealed both
aerobic and anaerobic organisms. Blood agar plates of
fluid showed streptococcus, staphylococcus, and many
gram-negative bacilli. Stab cultures resulted in diffuse
growth of anaerobic organisms.

Following the first aspiration, a fairly large hydro-
pneumothorax was seen by fluoroscopy and X-ray film.
The left lower lobe remained rigid, and the large round-
ed tumor mass extending from the first interspace anter-
iorly to the base was clearly seen. At the first and later
aspirations no air had been allowed to enter the chest,
and the presence of a fistula, due either to penetration
by the mass or to trauma caused by the aspirations, was
therefore assumed.

June, 1946

185

Fig. 2. Illustrates the new areas of infiltration in the
cardiophrenic angle and in the left base.

was made to provide an adequate fluid intake. From the
time of the first aspiration the patient developed left
chest wall infection. Multiloculated anaerobic abscesses
were present over the entire left anterolateral chest wall.

The patient was treated with continuous hot moist
compresses to the chest and with penicillin intrapleurally,
and also intramuscularly and intravenously. Penicillin
was given intravenously in doses of 50,000 units.

The physical condition of the patient rapidly became

Fig. 4. Pneumothorax is shown, following the first
two aspirations of over 2000 cc. of fluid. The mass is
clearly differentiated.

i'iC

Fig. 1. Shows the well demarcated left hilar mass.

On December 26 the patient began to complain of pain
in the epigastric region. Phenobarbital and codeine were
given for relief. On December 27, 1944, the patient’s
previous low-grade fever (99.4°) suddenly rose to 103°.
Sulfathiazole, 1 gram every four hours, with soda, was
begun, and was discontinued two days later because the
patient claimed that the medication caused more nausea.
The patient’s clinical course thereafter was marked by
toxicity, and frequent sedation and analgesia were re-
quired. Fluids were given intravenously, and an attempt

Fig. 3. The rounded mass now extends to the lateral
chest wall and fills the costophrenic angle.

186

The Journal Lancet

Figs. 5 and 6. Show different aspects of horizontal sections of the left lung. Note the white tumor
mass completely surrounding the aorta. Multiple abscesses and the area of caseous tuberculosis and
tuberculous pneumonia are shown.

hopeless, although the anaerobic chest wall infection
appeared to be improving. He expired on January 17,
1945, just eleven days after the development of the
massive putrid empyema and spontaneous pneumothorax
on the left. Diagnosis at this time was: 1. Pulmonary
tuberculosis, moderately advanced. 2. Severe tuberculous
laryngitis. 3. Mediastinal tumor, exact etiology to be
determined later.

Autopsy was done the following day. With the excep-
tion of neurofibromatoses well scattered over the patient’s
body, there were no external markings of note. When
the peritoneal cavity was opened a moderately large
amount of free gas was heard to escape. The omentum
was seen to be displaced upward in the region of the
liver and duodenum. Upon replacing it downward,
about 1000 cc. of intraperitoneal fluid were seen. This
fluid was thin, contained much fibrin, and was localized
in the region of the lesser omental sac. There was
marked congestion of the peritoneum and a marked
localized peritonitis in the duodenal and lesser omental
regions.

Examination of the duodenal cap revealed four duo-
denal ulcers, one of which had penetrated and showed
signs of recent hemorrhage. The diameter of this ulcer
measured % cm. There were many small, pinpoint white
nodules on the serosal surfaces of the jejunum. The
mesentery was also infiltrated with these white nodules,
which upon gross examination appeared to be tubercu-
lous. The peritoneal surfaces of the diaphragms were
glistening and normal in all respects. The kidneys,
adrenal glands, pancreas, gallbladder, and liver were
normal. The spleen was soft and "mushy” in character.
No nodules were present.

The chest wall was then removed without difficulty.
The entire left anterolateral chest wall contained multi-
loculated anaerobic abscesses, which appeared to be local-
izing. The right lung was adherent anteriorly and an-
terolaterally by large, diffuse adhesions. Nodules could
be felt in the apex of the right lung. The heart, aorta,

trachea, bronchi, esophagus, left lung, and the hard
posterior mediastinal mass were removed en bloc. The
left auricle was adherent to this hard mass, which ex-
tended in the paravertebral gutter from the 6th rib pos-
teriorly to the diaphragm. Upon examination the heart
was found to be normal. It was removed from this
mass. The tracheal portion of the right main stem bron-
chus was normal. The left main stem bronchus was
normal until it approached the level of the mass that
occluded it. The esophagus was removed from this mass,
and also the trachea to that point. The aorta was entirely
surrounded by this hard mass and could not be removed.

The lower lobe of the left lung was completely filled
with multiple abscesses, and appeared gangrenous. Sec-
tion of the left lung showed a 1.5 cm. bronchopleural
fistula, which led into the multiple abscessed areas. This
fistula was present just below the left interlobar fissure
in the anterior aspect of the left lower lobe. Horizontal
sections of the lung were taken, as shown in Figures
5 and 6. There was an intense pleuritis, and about
800 cc. of putrid empyemic material were present. Sec-
tions of tumor, lung, jejunum, and duodenum were re-
viewed by Dr. A. K. Saiki of the University of North
Dakota. His report was:

1. Prickle cell carcinoma (squamous) of lung meta-
stasis to periaortic nodes, with extension to and sur-
rounding the aorta.

2. Caseous tuberculosis and tuberculous pneumonia,
left lung.

3. Healed tuberculomas of jejunum, serosal.

4. Multiple duodenal ulcers, one with perforation.

5. Tuberculous laryngitis.

6. Anaerobic chest wall infection.

7. Bronchopleural fistula.

Discussion

This case presents seven distinct severe diseases. The
malignant tumor was diagnosed during life, as were the
pulmonary tuberculosis, tuberculous laryngitis, anaerobic
chest wall infection, and bronchopleural fistula. The

June, 1946

187

multiple duodenal ulcers, one with perforation, and
tuberculomas of the jejunum, as well as the specific
nature of the malignant tumor, were not diagnosed until
autopsy was performed.

In reviewing the case, it was seen that the reason for
the vomiting, high temperature, and pain in the epigas-
trium was the perforation of duodenal peptic ulcers. At
the time of treatment it was thought that the patient’s
condition, added to a sensitivity to the drugs, contraindi-
cated sulfathiazole by mouth. Positive sputum early in
this case suggested that we were dealing with several
pulmonary conditions. The presence of a moderately
large hydropneumothorax, in spite of very careful tech-
nique and the presence of an anaerobic chest wall infec-
tion, suggested the possibility that the mass perforating
into the intrapleural space had created the broncho-
pleural fistula.

It is obvious that with extension to the pleura in bron-

chopleural fistula the patient’s case was hopeless and
unamenable to surgery. Since there was no primary skin
cancer, it is possible that this prickle cell squamous car-
cinoma of the lung originated in the left bronchus.
Whether the patient’s chronic tuberculosis, evinced by
the healed tuberculomas of the jejunum, caused meta-
plasia and reversion to squamous epithelium in the bron-
chus is an interesting speculation. It is interesting to
note also that the intravenous, intramuscular, and topical
injections of penicillin seemed to be speeding the local-
ization of the anaerobic chest wall infection, in spite of
the very poor condition of the patient.

Figures 1, 2, 3, and 4 demonstrate the X-ray course
of this case.

Summary

A very unusual case of multiplicity of severe diseases
is described. The clinical course and gross microscopic
autopsy findings are presented.

THE DOCTORS MAYO AND THE FUTURE OF MEDICINE

"William and Charles Mayo did more to improve medical service to the public than any
other physician of their own or earlier generations. They were pioneers. They blazed new
trails in surgery, in many medical specialties. But of equal significance — perhaps of more
lasting significance — they blazed new trails in organization — in medical economics.

"Among leaders in medicine, the leaven continued to work. There is fermenting a desire
on the part of progressive physicians and the institutions with which they are associated
further to improve medical care, its organization, distribution, methods of payment, and
scientific content. Change is inevitable — as it must be in any dynamic science. The primary
interests of individual physicians may vary, but the objective of all is the same: to form
plans whereby better service may be assured to all of the American people.” — Thomas
Parran, in The Yale Review, Spring (March) 1946.

WHAT CAN A COUNTY MEDICAL SOCIETY DO WITH AN
EXTRA $500 ANNUALLY

A few years ago a member of the Adams County Medical Society in Illinois, with a
membership of sixty, set up an irrevocable trust or foundation for his society. He has since
contributed further to the trust, which now has an income of over $600 annually. The prin-
cipal must be held intact, and not to exceed 80 per cent of the income may be expended
annually, so the foundation will naturally grow. The trustees are empowered to use the
funds to sponsor or undertake one or more things of a charitable, scientific, literary, or edu-
cational nature "which will bring public and professional honor and respect to the medical
profession.”

The trustees know of no other foundation like this one, and are desirous of securing
counsel. Further particulars may be had from Dr. Ralph McReynolds, President, Swanberg
Medical Foundation, 1101 Maine Street, Quincy, Illinois. Dr. McReynolds will also appre-
ciate receiving suggestions for the foundation’s activities.

188

The Journal Lancet

Post'Measles and Post>Mumps Encephalitis

Stuart Lane Arey, M.D.

Minneapolis

Encephalitis may follow any of the contagious dis-
eases. Gordon 1 reports that at Kingston Avenue
Hospital, Brooklyn, New York, from 1935 to 1941 they
saw 56 cases of encephalitis following measles, 48 follow-
ing pertussis, 22 following mumps, 8 following chicken-
pox, and 5 following scarlet fever. There were no cases
following German measles.

Hoyne - reports 28 cases of post-measles encephalitis
out of 400 hospitalized cases. His cases were twice as
frequent in females as in males. The oldest of his patients
was 18 and the youngest 8 months. Hamilton and
Hanna 3 report the incidence of post-measles encephalitis
to be one per thousand or fifteen hundred cases. Ford 4
states that 0.4 per cent of all measles cases have central
nervous system symptoms.

The frequency of mumps encephalitis is reported to
be from 0 to 40 per cent.'J A relatively high percentage
of mumps cases may show changes in the spinal fluid
without any clinical evidence of encephalitis; that is,
there is a so-called latent encephalitis.6

Etiology

There is no apparent relation between the severity of
the infection, age, sex, race, or body type of the patient
and the incidence of encephalitis. Four theories of etiol-
ogy advanced are: (a) An augmentation of neurotropic
properties of the virus of the associated disease, (b) A
latent virus in the brain is stimulated by the basic disease,
(c) A hypothetic toxin liberated by the disease causes
demyelinization in the brain, (d) A local allergic re-
action in which the virus of the associated infection acts
as a sensitizing agent.

Shaffer 7 et al. were able to isolate the virus of measles
from the brain of a patient dying of post-measles en-
cephalitis.

Finley 8 draws an analogy between the allergic re-
action observed during smallpox vaccination as explained
by Pirquet and the changes observed in post-measles and
post-vaccinal encephalitis.

Putnam 9 believes that occlusion of the small blood
vessels in the central nervous system is the characteristic
lesion and that the primary difficulty is a change in the
clotting mechanism of the blood. He states that encepha-
lomyelitic changes similar to those observed in encepha-
litis following measles, mumps, and vaccination may be
produced by mechanically blocking the venules with in-
jection of lung extracts, brain extracts, carbon monoxide,
or potassium cyanide.

Clinical Course

In post-measles encephalitis the onset is usually two
to seven days after the appearance of the rash. In Ham-
ilton and Hanna’s series 3 the longest time elapsing was
eleven days from the onset of rash. Three types of onset

Read before the Minneapolis Academy of Medicine, March
18, 1946. From the Contagious Disease Service, Minneapolis
General Hospital.

are described: (a) Convulsions followed by coma in

50 per cent of cases, (b) Listlessness, drowsiness, and
coma in 40 per cent, (c) Delirium, irritability, and ex-
citement in 10 per cent.

Examination of the spinal fluid shows a clear fluid
under normal or increased pressure, with a moderate
increase in the cell count. The majority of cells are
lymphocytes. The protein is increased, and the sugar
is either normal or low. The spinal fluid may be entirely
normal; in fact, Litvak 10 says that fatal cases are likely
to have a normal or only slightly elevated cell count.

In favorable cases the temperature gradually subsides,
the neurologic symptoms disappear, and the patient
makes a good recovery.

In mumps encephalitis the onset may precede the
parotid swelling or may follow it by several days. There
is an elevation of temperature with headache and vom-
iting. Convulsions and coma are exceptional. The spinal
fluid findings are undistinguishable from those in polio-
myelitis. In general, the course is much milder than in
post-measles encephalitis.

Prognosis

The prognosis in measles encephalitis should be guard-
ed. Hoyne 2 had a mortality rate of 32 per cent in hos-
pitalized cases and gives a mortality in all cases of 6
per cent. Of 19 patients surviving, five were incapaci-
tated mentally. Hamilton and Hanna 1 state that, in
general, of ten patients four will completely recover, two
will die, and four will have one or more major or minor
residual symptoms. Ford 4 says 65 per cent will have
some residuals: 30 per cent some weakness, 12 per cent
ataxia, 17 per cent some personality change, and 5 per
cent epilepsy. Litvak 10 says 69 per cent will have
sequelae.

The prognosis in mumps encephalitis is much happier.
Donohue 5 says complete and uneventful recovery is the
rule. De Lavergne, Kissel, and Accoyer (1937) found
reports of only 12 patients who had died as a result of
the neurologic complications of mumps.

Pathology

According to Ford 4 the characteristic pathology is a
toxic degeneration. In the case reported by Shaffer 7
there were many small scattered hemorrhages, with an
accumulation of cells throughout the brain substance,
an infiltration of mononuclear cells, especially about the
small blood vessels, and many perivascular foci of early
demyelinization scattered throughout the brain.

Donohue 5 says the fundamental lesion in mumps en-
cephalitis is a perivascular demyelinization.

Therapy

Litvak 10 observed that no cases of encephalitis oc-
curred in patients who had received prophylactic conva-
lescent serum, whole blood, or placental extract.

Putnam,9 who thinks the fundamental difficulty lies
in some disturbance of the clotting mechanism of the

June, 1946

189

Table 1. Analysis of Ten Cases of Post-Measles Encephalitis

Spinal Fluid
All fluids were clear

Age

Sex

Days
after Rash

Sensorium

Convul-

sions

Fever

Sequelae

WBC

Cells

Per Cent Protein
Lymphs mg. 100 cc.

Sugar
mg. 100 cc.

Unconscious

105°

Died

18,800

180

Unconscious

105°

Died

9,950

100

185

Unconscious

106°

Died

3,350

100

Delirium

107°

Died

4,400

100

Unconscious

105°

14,500

100

151

Delirium

101.4°

11,100

months

Unconscious

104.2°

30,500

145

Unconscious

104°

Died

3,300

Lethargy

102.2°

4,400

Lethargy

100°

Mental

Deterioration

9,150

blood, suggests heparin therapy. He believes that serum
and intravenous medication of any kind are contraindi-
cated, as similar encephalitides may be brought on by
administration of sera.

Hamilton and Hanna 3 believe that shock therapy in
the form of intravenous typhoid vaccine gives the best
results.

Burton and Weir1J used sulfapyridine and intramus-
cular blood in treatment.

The therapy of mumps encephalitis is entirely symp-
tomatic. Carleton 13 advises against the use of spinal
puncture as either a diagnostic or therapeutic measure.
However, other authors 6 feel that spinal drainage may
be useful in relieving headache.

Analysis of Cases

The records of the Minneapolis General Hospital
show ten cases of post-measles encephalitis up to Janu-
ary 1946 (Table 1). The oldest patient was 7 years of
age and the youngest 10 months. The cases were divided
equally between sexes. The onset occurred 0 to 10 days
after the rash. In most instances the onset was stormy,
with convulsions in five cases, coma in six cases, delirium
in one case, and lethargy in three cases.

The spinal fluid showed 4 to 180 cells, with a predom-
inance of lymphocytes in all cases. The cell count tended
to be low in fatal cases. The spinal fluid sugar was
usually normal. There was normal or moderate eleva-
tion of the spinal fluid protein.

The white count varied from 3300 to 18,000, with
no evident prognostic import.

There was a mortality of 50 per cent. The follow-up
is not adequate, but of five recoveries one showed evident
mental deterioration at the time of discharge.

In six cases of mumps encephalitis (Table 2), the old-
est patient was 46 and the youngest was 4. There were
five males and one female. The encephalitis preceded
the parotid swelling in one instance and followed it up
to a week later in other cases. There was some lethargy,
headache, and vomiting noted at the onset. The spinal
fluid showed cell counts varying from 248 to 880, with
a predominance of lymphocytes. The remainder of the
spinal fluid findings were similar to those occurring with
post-measles encephalitis. The white blood count re-
mained normal in all cases.

All our cases of mumps encephalitis recovered, with
no mental sequelae. The only neurologic sequela noted
was a unilateral nerve deafness in one case.

Table 2. Analysis of Six Cases of Mumps Encephalitis

Age

Sex

Days after
Onset of
Swelling

Sensorium

Convul-

sions

Fdead-

ache

Vomit

Fever

Seque-

lae

WBC

Cells

Spinal Fluid
All Fluids Were Clear
Pressure

Per Cent (mm. Pro-
Lymphs H»0) tein

Sugar

Lethargy

102°

7000

536

140

136

Lethargy

102.2°

6000

433

135

Lethargy ±

102.8°

Deaf-

ness

8800

500

190

12 hours
before

Lethargy

103.8°

5200

248

Lethargy ±

102.8°

9650

880

Stupor

102°

6550

280

190

The Journal Lancet

I was unable to find records of encephalitis following
any other contagious disease at Minneapolis General
Hospital.

Conclusion

1. Ten cases of post-measles encephalitis and six cases
of post-mumps encephalitis are reported.

2. The prognosis in post-measles encephalitis is un-
certain, both as to life and sequelae.

3. The prognosis in post-mumps encephalitis is ex-
cellent.

4. Suggestions concerning etiology and therapy are
reviewed.

References

1. Gordon, M. B. In discussion of Litvak, A. M., Sands,

I. J., and Gibel, H.: Encephalitis Complicating Measles. Am.

J. Dis. Child., 65: 265-95 (Feb.), 1943.

2. Hoyne, A. L.: Measles in 1938. Illinois M. J., 76: 1 36 —
39 (Aug.), 1939.

3. Hamilton, P. M., and Hanna, R. J.: Encephalitis Com-
plicating Measles. Am. J. Dis. Child., 61: 483-93 (March),
1941.

4. Ford, F. R.: The Nervous Complication of Measles.

Bull. Johns Hopkins Hosp., 43: 140-84, 1928.

5. Donohue, W. L.: Mumps Encephalitis. J. Pediat.,

19: 42-52 (July), 1941.

6. Wesselhoeft, C.: Mumps. New England J. Med., 226,
13: 530-34 (March 26), 1942.

7. Shaffer, M. F., Rake, G., and Hodes, H. L.: Isolation of
Virus from Patient with Fatal Encephalitis Complicating
Measles. Am. J. Dis. Child., 64: 815-19 (Nov.), 1942.

8. Finley, K. H.: Pathogenesis of Encephalitis Occurring

with Variola and Measles. Arch. Neurol. & Psychiat.,
39: 1047-54 (May), 1938.

9. Putnam, T. J.: Newer Conceptions of Post Infectious and
Related Forms of Encephalitis. Bull. New York Acad. Med.,
17: 337-47 (May), 1941.

10. Litvak, A. M., Sands, I. J., and Gibel, H.: Encephalitis
Complicating Measles. Am. J. Dis. Child., 65: 265-95 (Feb.),
1943.

11. Quoted by Donohue, W. L. •’

12. Burton, A. H. G., and Weir, J. H.: Post Vaccinal and
Measles Encephalomyelitis. Lancet, 241: 561-62 (Nov. 8),
1941.

13. Carleton, W. T.: Mumps Encephalitis. U. S. Nav. M.
Bull., 41: 1401-4 (Sept.), 1943.

EARLY SYMPTOMS AND SIGNS OF ACUTE INFANTILE PARALYSIS

(A Hospital Report)

Particular interest has been given to the history of onset of the acute illness of all cases
coming to the Marmet (West Virginia) Hospital during the past two outbreaks of acute
infantile paralysis of 1944 and 1045. A total of 107 cases were admitted with the diagnosis
of infantile paralysis. Seventy-two of these cases were covered in a report last year in which
it was stated that every child was reported by the parents to have had a high temperature
at the onset of illness, was irritable or irrational and vomited. Intense headaches with sore
or inflamed throats were noted in almost all cases. A rigid spine and muscle soreness came
on very early and were noted in every case at the time of admission to the hospital.

The cases admitted in 1945 presented a different pattern, but certain symptoms were
constant in the two series, namely, vomiting, a rise in temperature or "high fever,” headache,
muscle soreness or weakness, sore throat, "taking cold,” stiff neck, stiff back, and stupor.
The symptoms are recorded in the order of their frequency.

As stated before, these symptoms and signs were listed as taken from the parents or the
patient, if capable of clear statements. It is surprising how often a history of a fall compli-
cates the picture and both parent and physician have often attributed all symptoms to the
accident.

Not every child whose illness starts with a stomach upset, sudden rise in temperature,
headache, muscle soreness with stiffness of back develops anterior poliomyelitis, but this com-
bination of symptoms should be a warning to the parent and physician to be on the alert for
the one disease of childhood that simulates so many other conditions. We have seen it sneak
in with bilateral otitis media, with multiple joint pains, whooping cough, epilepsy, and tonsil-
litis. Three cases in 1945 proved to be encephalitis and one case of brain abscess had been
erroneously diagnosed as poliomyelitis. Two cases of Guillain-Barre syndrome presented
many symptoms suggestive of "polio,” and one of these cases required the use of the iron
lung for five days, owing to the paralysis of chest muscles. The study of the spinal fluid
gives the differentiation needed in these cases.

Poliomyelitis is a very interesting, yet serious and tragic, disease, and one often difficult
to detect early. Fortunately, the physicians of West Virginia are ever mindful of the disease,
and they are to be complimented upon their alertness, for it has been our experience that the
sooner the cases are recognized and given the proper treatment, the less tragic the results.
In practically all cases admitted, the attending physician had made the diagnosis and arranged
for hospital care on the first visit to the child. This is a record probably not equalled in any
similar community. — E. Bennette Henson, M.D., Manager, Marmet (West Virginia)
Hospital.

June, 1946

191

Filariasis and Malaria on the Campus

Ellis Herndon Hudson, M.D., Captain (MC) USNR
Athens, Ohio

The two parasitic diseases that elicited most attention
during World War II were filariasis and malaria.
There is a superficial resemblance between the two in
that both are carried by mosquitos, but beyond that they
have little in common.

Filariasis cases in the Navy arose almost exclusively
among Marines who saw service in the Samoan group
of islands, and though these men were once the source
of much official anxiety, the passage of time has almost
completely relieved the situation. It is still possible, how-
ever, that such an ex-Marine or Army man who had
duty in the Pacific area may present himself in a student
health clinic. Examination of such a case would prob-
ably reveal a minimal degree of adenopathy and some
nodulation or thickening along one or both cords. There
may be complaint of fatigue or aching in this area.

In general one may offer such a patient genuine re-
assurance. The prognosis for complete relief of all symp-
toms has been established on the basis of the experience
of recent years. A good deal of the difficulty in such
cases is psychoneurotic, associated with difficulties, im-
agined or real, in connection with marriage or reproduc-
tion. Here again psychotherapy is indicated, and if the
patient’s confidence can be secured the symptoms should
be entirely relieved. There is no specific treatment for
the parasite; in fact, it is highly probable that such para-
sites as were once present have now died and become
walled off and calcified.

Filariasis is a disease of natives who have been bitten
by mosquitoes ever since they were born. We know that
such individuals by the time they reach maturity harbor
innumerable parasites and often have untold millions of
embryo parasites in their blood. The end results of filaria-
sis in such natives are naturally not to be expected in
Marines who have spent only a few months in the en-
demic area and are now completely removed from possi-
bility of reinfection.

Turning now to malaria, I may point out that the ma-
laria parasite has a much more perfect life cycle than
the filarial worm, for there is multiplication of parasites
not only in man but also in the mosquito. The multipli-
cation in both hosts is at so swift a rate as to make the
malaria parasite one of the most successful in its field.

A very useful concept which has become current in
the past few years regards malaria in the human subject
as occurring in two phases, one in the tissues and one
in the blood.

During the tissue phase the parasite rests in the liver,
spleen, bone marrow, and reticulo-endothelial system,
without causing any clinical symptoms. It is apparent
that malaria can remain thus in the human body for
months or even years without affecting the health in any
respect. This we call the latent phase, and the parasite

Presented at the Annual Meeting, Ohio Student Health As-
sociation, Columbus, April 5, 1946.

is said to be in its extra-erythrocytic form. Though this
so-called EE form has been found in bird malaria it has
never been identified in man. It is a strange fact that
in spite of diligent effort to identify it during the tissue
phase, the parasite is lost as soon as the mosquito intro-
duces it into the human body and we do not pick it up
again until it appears as a small ring in the red cell.
We may call this a hypothetical stage of the parasite,
but it is hypothetical only in the sense that we have not
identified it. It produces no symptoms and apparently
lives in perfect harmony with the human tissues.

What is it that changes the tissue phase into the blood
phase? We do not know, although we know some
things that seem to precipitate the parasites out of the
tissues into the blood. In a proportion of cases the
parasites introduced by the mosquito are disposed of in
the tissue phase. These patients never have a symptom.
In other cases the parasites may cause but one explosion
in the blood phase and none thereafter. These are the
patients who have had only one "attack” of malaria.
In a third group attack after attack may appear in the
blood phase, alternating with asymptomatic periods when
the infection retreats temporarily into the tissue phase.
The malaria cases with which we were most concerned
in the military service were in the last group, namely,
those with repeated relapses. These were due almost en-
tirely to vivax infection.

A notable point in regard to malaria as now seen
among veterans is that it is solely concerned with this
vivax infection, and this is comforting, since no one dies
of this type of malaria. In this sense it merits its name,
benign tertian, though it may sometimes seem by no
means benign, considering the severity of the paroxysms.
If you ask why falciparum and quartan infections are
excluded, the reply is that falciparum has been screened
out by treatment and by the passage of time, and that
quartan is a rare infection and one prone to extreme
latency.

The malaria case that we encounter on the campus
today is therefore of the benign tertian type in a subject
who, in the majority of cases, has had his infection for
a year or more and has had a number of attacks, each
terminated by treatment. What such a person requires
is an exhortation to live according to a regular hygienic
program and to secure prompt treatment when an attack
seems imminent. He should be told that he is building
up his immunity whether he has attacks or not and that
with the passage of time the attacks will become less
violent and less frequent. It is extremely rare for any
patient to exhibit symptoms of vivax infection for as
long as three years, barring reinfection.

The patient’s friends should be told that if he is well
treated with each attack he is no menace to his com-
munity, though there may be anopheline mosquitoes in
the vicinity. If he is treated promptly he need not an-

192

ticipate more than one paroxysm with each attack. Thus
if treatment is systematic the disease has no deteriorating
effect upon the general health. The current impression
to the contrary is based on experience in this country
in areas where malaria is widespread, chronic, and often
untreated.

A word about drugs. These are now two in number,
but there will shortly be three. Quinine is the oldest,
atabrine (quinacrine) is the best one so far, and chloro-
quine is the newest and perhaps will supersede the others.
Considerable work was done on this chemical during the
war, but its superiority, although admitted, was not suf-
ficiently great to justify scrapping all the routine anti-
malarial treatment programs of the Army and Navy.

The Journal Lancet

On the campus today either quinine or atabrine is per-
fectly suitable.

It should be remembered that these drugs are effective
only against the blood phase. We have absolutely no
drug that kills the parasite of vivax malaria in the tissue
phase. To know this fact is fundamental to an under-
standing of the therapy of malaria. We have to remind
ourselves that we are not curing the disease when we
stop the fever and the paroxysms; we are merely termi-
nating the obvious or apparent phase and driving the
infection back into the inapparent phase. If we do this,
however, our patient will assuredly get well, because in
the course of time he will develop his own immunity.

MALARIA

" . . . The decline in malaria incidence, beginning in the prewar years, apparently continued
through 1944 and 1945. This favorable situation probably reflects the gratifying result of
special malaria control activities conducted by the civilian and military authorities in ma-
larious areas.

"According to cases reported by the State health officers, the incidence of malaria in
the United States has been steadily declining since 1935. The latest cyclic peak of reported
malaria cases and deaths occurred during the period 1933-36. In 1932 a total of 68,613
cases was reported in the United States, with 2,540 deaths, but a sharp increase in both
malaria morbidity and mortality was recorded in 1933, when 125,549 cases and 4,678 deaths
were reported. In 1935 these figures were 137,502 and 4,435, respectively. By 1938 the
number of reported cases had dropped to 84,206 and the number of deaths to 2,378. The
malaria death rate in the United States declined from 3.7 per 100,000 population in 1933
to 0.5 in 1943. The average of the monthly rates for 1945, based on a 10-percent sampling
of death certificates, is approximately 0.4.

"The proportion of malaria cases that relapse is not known. It is understood that, in
the absence of information to the contrary, it is the policy of the Medical Statistics Division
of the Office of the Surgeon General of the Army to record as overseas infections cases
occurring within one year of the return of the patient from overseas. Public Health Service
and other investigators have demonstrated that Plasmodium vivax malaria cases contracted
by soldiers in foreign countries (South Pacific, Mediterranean, and South American areas),
which relapse after the men return to the United States, is infective to species of the native
American anopheline mosquitoes, and that these mosquitoes infected by imported vivax ma-
laria can transmit the disease by biting a susceptible person. If reliable information can be
secured during the current year on the numbers of indigenous cases and relapses of overseas
infections it will afford an index to the effect of the thousands of cases of malaria in men
returned from overseas, and local distribution will show whether the disease has appeared
in formerly malaria-free areas.” — Brock C. Hampton, U. S. Public Health Service, in
Public Health Reports, May 10, 1946.

June, 1946

193

Oxygen Therapy

Joe W. Baird, M.D.
Minneapolis

Aristotle in 350 b.c. recorded the first experiments
l in respiration, but it was not until 1775 that oxy-
gen was discovered by Joseph Priestley. Even then he
did not realize the significance of his discovery, and it
remained for Lavoisier (1775-1794) to demonstrate that
the gas was absorbed by the lungs, burned in the tissues,
and eliminated as carbon dioxide and water.

The discovery of oxygen aroused considerable interest
in medical circles, and in 1798 Beddoes established his
Pneumatic Institute. Here oxygen was used as a panacea.
Like all such cure-alls it rapidly fell into disrepute from
misuse and abuse. As a result of this unfortunate ex-
perience, it was not until the beginning of World
War I that oxygen therapy again became popular. How-
ever, in the intervening years much study and research
was done on the subject which prepared the way for
the place oxygen therapy was to occupy in therapeutic
medicine.

Uses of Oxygen Therapy
As a therapeutic measure, oxygen is used mainly to
combat anoxia. Anoxia, as it is recognized today, may
be divided into four classes, namely, the anemic, the
anoxic, the stagnant, and the histotoxic forms. In the
anemic form the oxygen tension in the blood is normal,
but the oxygen content is limited because of insufficient
hemoglobin. The primary anemias are an example. In
the anoxic form the hemoglobin is unsaturated because
of a lowered oxygen tension. This condition may result
from breathing atmospheres with a reduced oxygen con-
tent or from any condition that leads to a reduced
alveolar ventilation.

Stagnant anoxia is the end result of cardiac or circu-
latory failure. The oxygen tension and oxygen content
are normal, but the tissues are inadequately supplied
because of a retarded blood flow. This condition is fre-
quently seen in traumatic and surgical shock. Histotoxic
anoxia is a condition in which the oxygen tension and
content are essentially normal but the cells are incapable
of utilizing the available oxygen because of poisoning.
Examples are cyanide and carbon monoxide poisoning.
Effects of Oxygen Want
Studies have shown the effects of oxygen want. These
studies were made at high altitudes or in closed cham-
bers in which the oxygen content could be reduced to
varying levels. It has been shown that there are no defi-
nite signs of oxygen want in normal individuals until
the oxygen has been reduced by 7 per cent. This slight
deficiency results in an accelerated heart rate and mod-
erate hyperpnea. A still greater reduction of oxygen
will lead to headache, nausea, vomiting, and visual dis-
turbances.

If the content is reduced further, convulsions, coma,

Read before the Minneapolis Academy of Medicine, Novem-
ber 19, 1945.

and eventual death result. If the onset of anoxemia is
insidious the symptoms are those of mild alcoholic in-
toxication, with exhilarated mental functions, impairment
of judgment, amnesia, and varying types of emotional
disturbances. "Pilot error” has been definitely traced to
varying degrees of anoxemia. It has been shown that a
mild degree of oxygen want develops at 10,000 feet alti-
tude, that oxygen want is definitely evident at 12,000
feet, and is well marked at 15,000 feet. For this reason
pilots are instructed to use oxygen if flying above 10,000
feet for more than 30 minutes.

Cyanosis, which results from high altitudes or cardio-
respiratory disease, is not evident until the oxygen con-
centration of arterial blood has fallen to 85 per cent.
It should be borne in mind that the bluish color is pro-
duced by the reduced hemoglobin, not by the degree of
saturation of hemoglobin with oxygen. Thus the anemic
patient with only 5 grams of hemoglobin may not show
cyanosis even though he is suffering from serious arterial
oxygen saturation. On the other hand, the patient with
polycythemia, who has 7 million red cells instead of the
normal 5 million, may show cyanosis with an arterial
oxygen saturation of 93 per cent, since 7 per cent of
his relatively large total hemoglobin is in a reduced state.

In the absence of cyanosis, a pulse rate out of pro-
portion to the degree of hyperpyrexia and the presence
of a grayish color and rapid, shallow respirations are
clearly indicative of anoxia, and steps should be taken
to correct the condition at once.

Indications for Oxygen Therapy

It has been stated 1 that the efficacy of oxygen is vir-
tually in direct proportion to the day on which oxygen
therapy is started, particularly in pneumonia and cardiac
disease. Chemotherapy has markedly altered the course
of many diseases, particularly pneumonia. However, it
does not eliminate the danger of anoxia and the neces-
sity for early oxygen treatment.

The patient suffering from cardiac disease is usually
greatly improved by oxygen therapy. The cyanosis, dysp-
nea, and orthopnea are usually improved, and the patient
is consequently more comfortable. Aside from adding
to the patient’s comfort, oxygen therapy will often pre-
vent circulatory collapse and ultimate pulmonary edema.
The pain of coronary thrombosis has been shown to be
due to myocardial ischemia. The administration of oxy-
gen to these patients has in many cases offered marked
relief of pain.

Pulmonary edema responds very well to oxygen ther-
apy. However, in these cases the oxygen should be ad-
ministered under increased pressure. A positive pressure
of 4 to 5 cm. of water should be used. As the edema
improves, the pressure is gradually reduced to 1 or 2 cm.

Oxygen in combination with other gases is at times
indicated, especially in cases of asthma and hiccough.
Asthmatics are frequently afforded marked relief by

194

The Journal Lancet

administration of oxygen 20 per cent and helium 80 per
cent.

Persons suffering from hiccough frequently get relief
from the addition of carbon dioxide to the oxygen mix-
ture. The usual mixture used is oxygen 90 per cent,
carbon dioxide 10 per cent. The patient is allowed to
breathe this mixture until marked hypernea develops.
It is then discontinued and repeated at intervals of 15
to 30 minutes, if necessary, to control the paroxysms.

Aside from diseases of the cardiorespiratory system,
oxygen therapy is indicated in many other diseases.
Fine ■ and his co-workers have demonstrated that the
administration of 95 per cent oxygen will remove nitro-
gen from an obstructed bowel and thus lessen distention.
They also demonstrated that pure oxygen will lessen the
post-encephalogram headache.

Mayo 3 concluded that the administration of 100 per
cent oxygen postoperatively to surgical patients leads to
a smoother convalescence in many instances. Oxygen
therapy is indicated in many other diseases, particularly
in cases of shock, coma, hyperpyrexia, thyroid crisis,
postoperative atelectasis, asphyxia of the newborn, and
gas poisoning.

Methods of Administering Oxygen

At present we have four popular methods for the ad-
ministration of oxygen: intranasal catheter, tent, mask,
and chamber. The method used depends largely upon
the available equipment and the concentration of oxygen
to be delivered. There has been much discussion as to
the relative merits of low oxygen concentrations and the
dangers of high concentrations. It is generally agreed
that concentrations below 40 per cent are of little value.
The value of higher concentrations is recognized; but
the dangers of the higher concentrations are also recog-
nized. To be safe, it is advisable not to administer 100
per cent oxygen continuously for more than 48 hours.
The concentration should then be reduced to 50 or 60
per cent for 1 to 2 hours. If necessary, the concentration
may then be changed back to 100 per cent.

The periodic removal of the mask for washing the
face, feeding, and so on is usually enough to alter the
continuous administration of the high oxygen concen-
tration and thus eliminate the danger of oxygen poison-
ing, which is characterized by pulmonary edema and
areas of consolidation resembling bronchial pneumonia.

The intranasal catheter is a very satisfactory method
for administering oxygen in concentrations of 40 to 70
per cent. A flow of 5 to 8 liters of oxygen per minute
will usually deliver these concentrations to the patient.
A number 10 F. catheter is passed through one nostril
and the tip is anchored opposite the uvula. If the pa-
tient begins swallowing after the oxygen is turned on,
the catheter should be withdrawn slightly. It is advisable
to remove the catheter every 6 to 8 hours for cleaning.
After cleaning, the catheter should be placed in the op-
posite nostril to prevent irritation to the lining mem-
branes of the nose. As pure oxygen is very drying to
the nose and throat, some means for humidifying it
must be available. Humidifiers may be purchased, and
they add markedly to the patient’s comfort and the
effectiveness of the treatment.

Intranasal oxygen has several advantages. In the
hands of the inexperienced, this method is usually the
most satisfactory. Other advantages are that the cost
of equipment and its upkeep are less than for the tent
or chamber, and, lastly, that the expense to the patient
is less.

The mask is used for administering oxygen concentra-
tions of 70 per cent and above. A flow of 6 to 8 liters of
oxygen per minute will deliver these concentrations if a
well-fitting mask is used.

There is one important objection to the oxygen mask;
it becomes uncomfortable to the patient after he has
worn it for several hours. He begins to perspire beneath
the mask, it begins to feel too tight, and frequently it
becomes quite uncomfortable; for this reason it is not
tolerated by some patients.

The oxygen tent will deliver an available oxygen con-
centration of 40 to 60 per cent oxygen to the patient.
A flow of 10 to 12 liters of oxygen per minute is neces-
sary to furnish these concentrations in the inspired air.
However, these concentrations are available only if the
tent is managed correctly. If improperly managed, this
form of therapy may be ineffectual and even dangerous.

A properly managed oxygen tent furnishes a pleasant
means of oxygen administration. The patient is unham-
pered by tubes or masks, and he lies in a pleasantly
cooled, humidified atmosphere, breathing the oxygen-
enriched air. The tent is necessary for the administra-
tion of oxygen to small children and the older, non-
co-operative patient, who usually do not tolerate the
mask or intranasal catheter.

The chamber furnishes the ideal method for adminis-
tering an oxygen-enriched atmosphere. While this meth-
od is ideal, it is more expensive and is to be had only
in the larger hospitals, which have specially built rooms
for this purpose.

Misconceptions about Oxygen Therapy

Although oxygen therapy is a well-established form of
treatment, many physicians discount its effectiveness.
Such opinions arise from unfavorable experiences with
this rather expensive form of treatment. For this rea-
son, oxygen therapy is too often used only as a last
resort, to impress upon the patient’s family that every-
thing is being done for his welfare.

Let us analyze the factors underlying the failure of
this form of treatment to produce the desired results and
see if we are able to determine the factors that may have
led to failure. LJnfortunately, there is more to oxygen
therapy than wheeling in an oxygen tent, placing it over
the patient’s bed, and turning on a valve. This is the
first misconception of this form of treatment. As in any
form of treatment, there must be definite indications,
and once these indications are determined, steps must be
taken to insure adequate carrying out of the treatment.

In most hospitals oxygen therapy is the "orphan child”
of the therapies. There just seems to be no place for it,
and even if a place is found trained personnel for its
management is usually lacking. Because of this situation,
equipment is frequently in poor repair, obsolete, and
ill functioning. All these conditions lead to unsatisfac-
tory results. If oxygen is to be administered successfully

June, 1946

195

the equipment must be in good repair and properly
managed.

It has been proved that the concentration of oxygen
in the inspired air must be at least 40 per cent if oxygen
therapy is to be effective. Yet many tests have shown
the concentration of oxygen in the tent to be only 25
or 30 per cent. This low concentration of oxygen is
usually due to a torn tent, improper adjustment of the
canopy over the bed to insure a tight fit, too frequent
opening of the tent, or an inadequate oxygen flow.
There must be a flow of 10 to 12 liters of oxygen per
minute into the tent to have a concentration of 50 per
cent oxygen in the inspired air; nevertheless, many ob-
servations have shown a flow of only 6 liters per minute.
All these factors lead to an oxygen concentration too
low to be effective. Aside from adequate oxygen con-
centration within the tent — which can be maintained
only by periodic analysis of the oxygen concentration —
the tent must be properly cooled and humidified. These
conditions for satisfactory results can be maintained only
by having someone in charge who is familiar with this

AMERICAN STUDENT HEALTH

The American Student Health Association, an organi-
zation of two hundred colleges and universities through-
out the country, with two in Canada, represented at an-
nual meetings by members of their departments of stu-
dent health, held its 24th annual meeting in Minneapolis,
May 7—9.

Visits to the University of Minnesota Student Health
Service and the hospitality of the staff are pleasant mem-
ories of those who attended.

High points of the professional sessions. In the ses-
sion led by Dr. J. P. Ritenour, Pennsylvania State Col-
lege, a keen interest was shown in faculty health prob-
lems. It was conceded that since faculty members are
in a different age group from that usually served by
college health services, and therefore present different
types of health problems, significant increases in staff
and financial support would be required were the services
to assume the medical care of faculties. An alternative
approach to the problem was seen in the recently devel-
oped independent plans for prepayment medical services.

Dr. Bruce Dill of the Fatigue Laboratory at Harvard
offered a test for determining the physical fitness of stu-
dents. It is the result of months of study of various
methods for measuring reactions to strenuous exercise
in students and military trainees.

Dr. Wesley Spink, University of Minnesota, warned
of the danger of small and inadequate dosages of sulfa
drugs and penicillin, as usually present in sprays, pow-
ders, and lozenges. Such inadequate dosage often per-
mits the development of strains of organisms which are
resistant even to large doses of these drugs when used
later in the course of treatment.

An increased emphasis on health education in colleges
is demanded by the national and international develop-
ments of today. The San Francisco Charter contains an
important section on health. Disputes between manage-
ment and labor are concerned with the health of em-

type of therapy, rather than the untrained nurse or
orderly or the uninterested intern.

If oxygen therapy is to be effective it should be start-
ed early. Above all we must maintain at all times an
oxygen concentration that will correct the existing anoxia.
Otherwise this form of therapy will prove to be only a
disappointment to the physician and an added expense
to his patient.

References

1. Evans, J. H , and Durshordwe, C. J.: Indications for

Oxygen Therapy in Respiratory Disease. Anesth. & Analg.,
14: 162 ( July-Aug.) , 1935.

2. Fine, Jacob; Banks, B. M.; Sears, J. B.; and Hermanson,
Louis: The Treatment of Gaseous Distention of the Intestine
by the Inhalation of Ninety-Five Per Cent Oxygen. Ann.
Surg., 103: 375 (March), 1936.

3. Boothby, W. M.; Mayo, E. W.; and Lovelace, W. R.:
One Hundred Per Cent Oxygen: Indications for Its Use and
Methods for Its Administration. J.A.M.A., 113: 477 (Aug. 5),
1939.

4. Tovell, Ralph M., and Remlingen, Joseph, Jr.: History
and Present Status of Oxygen Therapy and Resuscitation.
J.A.M.A., 117 (Dec.), 1941.

5. Barach, Alvan L.: Inhalational Therapy. Philadelphia:

J. B. Lippincott Company, 1944.

ASSOCIATION NEWS-LETTER

ployees. To provide leadership in this field and to de-
velop an enlightened citizenry the college must recognize
its responsibility. This was the appeal made by Dr.
A. O. De Weese of Kent State University and his
committee on health instruction.

Dr. Warren E. Forsythe, University of Michigan, on
the basis of a detailed statistical analysis of the services
rendered civilian and veteran students, expressed the
opinion, shared by many delegates, that the problems
presented by veterans are not greater or fundamentally
different from those presented by civilian students.

However, Dr. Robert Hinckley, University of Minne-
sota, gave case histories of veterans with war-related
emotional problems and demonstrated that a psychiatrist
can be of great service in helping students, veterans or
civilians, to adjust themselves to the problems and situa-
tions facing them.

Dr. Holden, University of Colorado, reported on the
basis of his experience that veterans may be the carriers
of intestinal diseases, such as amebiasis, and so threaten
the health of the campus community.

As with all such meetings, the memories most likely
to last are those of the people met, of exchanges of in-
formation with others facing similar problems, of infor-
mal debates around the luncheon table. Talking with
others from all over the country, one realizes that the
health of college students is a national problem needing
the coordinated and united efforts of all departments on
the college campus interested in health. Dr. Ralph Ca-
nuteson, University of Kansas, stressed this need in his
presidential address. Later he announced that a third
national conference on health in college would be held
in New York, in May 1947, to be sponsored by four
national associations, namely, the Association of Ameri-
can Colleges, the National Education Association, the
National Health Council, and the American Student
Health Association.

196

The Journal Lancet

The Treatment of Trimalleolar Fractures of the Ankle

Major Robert E. Van Demark, M.C., A.U.S.

Camp Joseph T. Robinson, Arkansas

A single fracture at the ankle is frequently difficult
to reduce and may result in prolonged disability.
In case of a trimalleolar fracture, where the distal end
of the tibia is fractured at two points — medially and
posteriorly — and the distal end of the fibula is also frac-
tured, the attending surgeon is faced with a very defi-
nite problem. Failure to restore the fractured fragments
to their normal position frequently results in a painful
ankle and ultimately a degenerative arthritis.1 Incon-
gruity of the joint surface should be avoided and the
anatomical positions of the fractured fragments should
be restored.

Delayed reduction of the fracture is not advisable.
The resulting severe swelling obliterates the normal ana-
tomical landmarks at the ankle within a few hours, and
materially adds to the difficulty of direct manipulation
of the medial and lateral malleoli. Reduction of the
fracture is most easily effected within six hours of the
injury.

The choice of anesthetic varies with the age and con-
dition of the patient. A general anesthetic, a low spinal
anesthetic, or a local anesthetic in the fracture-hemat-
omas may be used. It is noted that the use of a local
anesthetic (2 per cent procaine solution) is usually un-
satisfactory because of failure to inject the solution into
the posterior fracture-hematoma. Such an injection is
preferably made from a point just behind the lateral
malleolus. A few cubic centimeters of the solution are
also injected directly into the ankle joint.

Fig. 1. Trimalleolar fracture with displacement of astragalus
posteriorly.

Closed reduction 2 of the fracture can usually be
effected (Figures 1 and 2). The method of reduction
varies with the individual case. It is essential that the
astragalus be replaced to its normal position under the

Fig. 2. Same case as shown in Figure 1. Closed reduction
under local anesthesia.

Fig. 3. Combined fracture of medial and (inner) posterior
malleoli with fracture of lateral malleolus. A small bone frag-
ment, displaced into the joint, is seen adjacent to the astragalus
medially. A satisfactory closed reduction could not be effected
despite repeated manipulation.

distal tibia by manual traction on the heel. Subsequently
the lateral and medial malleoli can be replaced in their
normal positions by direct manipulation.

June, 1946

197

Fig. 4. End result of case shown in Figure 3, following open
reduction and internal fixation which was removed.

Plaster of paris immobilization is the method of choice.
A minimum amount of padding should be used, in order
to avoid redisplacement of the fracture. Care must be
taken to avoid undue pressure on bony prominences.
With a padded cast bivalving is unnecessary. The
affected extremity should be well elevated and closely
observed for signs of circulatory embarrassment.

Open reduction of the fractured fragments is rarely
necessary and should be undertaken only under the most
rigid conditions of aseptic technique. In contrast to soft
tissue, infection of bone results in prolonged drainage
and disability. Only after repeated manipulations have
failed and where a strict aseptic technique can be relied
upon is open reduction justifiable (Figures 3 and 4).
An appropriate incision should be followed by accurate
reduction of the unreduced fragment or fragments.
Inert materials, such as vitallium or stainless steel, are
those of choice for internal fixation.

Immobilization is usually continued for a period of
ten weeks. Following the removal of the cast the judi-
cious employment of physical therapy is advisable.4
Weight bearing is begun two weeks later. The use of
an elastic bandage about the foot, ankle, and lower leg
will prevent the appearance of the edema frequently seen
following the removal of the cast.

References

1. Ghormley, Ralph K.: The Relationship of Fractures to

Severe Painful Joint Lesions of the Lower Extremity; an Edi-
torial. Surg. Gynec. & Obstet., 76: 752-53, 1943.

2. Key, J. A., and Conwell, H. E.: The Management of
Fractures, Dislocations and Sprains. Third Edition. St. Louis:
C. V. Mosby, 1942.

3. Lundy, John S. Clinical Anesthesia: A Manual of Clin-
ical Anesthesiology. Philadelphia: W. B. Saunders, 1942.

4. Van Demark, R. E., and Krusen, F. H.: Uses of Physical
Therapy in the Practice of Orthopedics. M. Clin. North
America, 27: 913-22 (July), 1943.

ROCKY MOUNTAIN SPOTTED FEVER SEASON APPROACHES

Rocky Mountain spotted fever occurs in a large number of states. It is conveyed to
human beings by the bites of ticks. In eastern and southern states the vector is the dog tick,
in the northwest it is the wood tick, and in southwestern states it is occasionally the lone
star tick.

The symptoms of Rocky Mountain spotted fever appear suddenly. They include fever,
headache, extreme sensitiveness of the eyes to light, pains in the muscles and joints, and
chills. A rash spreads over the body after the third or fourth day of fever.

About 20 per cent of Rocky Mountain spotted fever cases have been fatal. However,
vaccination reduces the chance of infection and lowers the fatality rate. A serum also is
available for treatment, and a new treatment recently has been tried by doctors.

Precautions to be taken against Rocky Mountain spotted fever include avoiding tick-
infested areas, vaccination of persons whose work takes them into tick areas, and careful
search of the clothing and the body at noon and at night after going into the woods during
the tick season. Ticks can be recognized by their flat, leathery appearance, and their eight
legs. If a tick is found on the person it should be removed carefully with tweezers or a
piece of paper so that it will not be crushed, and so that the fingers will not come in con-
tact with it.

198

The Journal Lancet

Book TUvUws

Surgical Treatment of the Motor-Skeletal System. Super-
vising Editor, Frederic W. Bancroft, A. B., M.D. , F.A.C.S.;
Associate Editor, Clay Ray Murray, M.D., F.A.C.S.
Philadelphia: J. B. Lippincott Company, 1945. 2 volumes.
Pp. 1254, illustrations 1061. $20.00.

Drs. Bancroft and Murray have succeeded in editing a com-
prehensive treatise which will take its place as a standard and
authoritative work in its field. These volumes represent the
combined efforts of 42 surgeons, all men recognized nationally
as authorities in their special fields of interest. Some of the
authors, together with the chapters they have written, are as
follows:

Frank R. Ober, M.D., Congenital Anomalies of Upper Ex-
tremity and Shoulder Girdle
A. H. Brewster, M.D., Congenital Dislocation of Hip
Mather Cleveland, M.D., Anterior Poliomyelitis
Joseph A. Freiberg, M.D., Low-back Pain
Bradley L. Coley, M.D., Tumors of Bones and Joints
Frank D. Dickson, M.D., Tuberculosis of Bones and Joints
William Darrach, M.D., Compound Fractures
Paul B. Magnuson, M.D., Treatment of Fractures of Bones
of Forearm.

In keeping with the times, the text has been streamlined and
made to fit the needs of the busy practitioner and surgeon, who
is more concerned about present-day authoritative opinion than
in the historical background of the subjects covered. The em-
phasis is placed primarily on modern surgical treatment. As
Dr. Bancroft says in a prefatory note, ", . . no attempt has
been made in general to present the diagnostic problems or the
etiology.” He states further, "It seemed advisable to establish
a pattern of treatment and coverage for each field which would
safeguard against omissions and would present the up-to-date,
authoritative material in the most concise and usable form.
This pattern would include not only the operation itself, but
also indications for it, a full discussion of the preoperative
preparation of the patient, the common sequellae, a full pres-
entation of the prognosis, and a complete discussion of the most
approved postoperative treatment.”

As the title indicates, the scope of the book is broad indeed.
The subjects covered transcend the bounds that general sur-
geons even now are willing to place on the sphere of activity
of the orthopedic surgeon. For that reason both the orthopedic
surgeon and the general surgeon will find much of interest in
these volumes. Those interphases between the admittedly arti-
ficial boundaries between the two great subspecialties of the art
and science of surgery are fully covered. Even the domain of
neurosurgery is touched upon by a fairly comprehensive treat-
ment of the prolapsed intervertebral disc. Lesions of the spinal
cord and peripheral nerves, however, are not discussed directly.

The chapter on "Anterior Poliomyelitis” contains discussions
of the aDproved methods of treatment for each stage of the
disease. Paragraphs added by the editor give a fair outline of
the so-called Kenny method of treatment, but no appraisal is
made of the value of this much debated regimen. As would
be expected, the orthopedic phases of treatment for the late
stages of the disease are dealt with in detail and completely.

The d iscussion of recurrent dislocation of the shoulder joint
is written in an admirably objective fashion. Reasons are given
for the failure of many of the operations for this condition rec-
ommended in the past, and then four operative procedures used
generally today are presented. The reader is left to draw his
own conclusions as to the relative worth of these procedures
No comparative statistics or reported series are given.

The two chapters outlined above are typical of the entire
work. There is a notable lack of percentages and statistics
throughout both volumes. Each chapter is accompanied by a
relatively short bibliography of modern articles on the subject
concerned.

As in most surgical books being published these days, a
section on military surgery has been included. Surgeon General

Kirk and Colonel Moore have written a comprehensive chapter
that outlines the methods of treatment used during the early
phases of war. For obvious reasons of time, it fails to include
many of the developments in surgical treatment that came about
slowly as the war progressed. The complete authoritative treatise
on military surgery as it developed and was practiced in World
War II is yet to be written.

Little more in criticism of this work can be said, except that
references to the role of penicillin in the surgical treatment of
the motor-skeletal system are rare and sketchy. Here again,
however, the time of publication and the rapid daily advances
in the subject would appear to be to blame, rather than willful
omission of the subject. — J. R. P.

A Bibliography of Infantile Paralysis, 1789-1944, with
Selected Abstracts and Annotations. Prepared under di-
rection of the National Foundation for Infantile Paralysis,
Inc. Edited by Morris Fishbein, compiled by Ludvig Hek-
toen, M.D., and Ella M. Salmonsen. Philadelphia: J. B.
Lippincott Company, 1946. Pp. 672. $15.00.

A thorough and complete bibliography, with abstracts of
some of the longer and more important articles. It is dedicated
to Franklin Delano Roosevelt, "who by his triumph over the
most dreaded of crippling diseases, which could not conquer
him, gave inspiration and courage to thousands of children,
men and women similarly afflicted.” Of great value in any
library where a study of infantile paralysis might be under-
taken—J. L. W.

LATEST BOOKS RECEIVED
Active Psychotherapy, by Alexander Herzberg, M.D.
New York: Grune & Stratton, 1945. Pp. 152. $3.50.

Amputation Prosthesis, by Atha Thomas and Chester
Haddan. Philadelphia: J. B. Lippincott, 1945. Pp. 306.
$8.00.

The Clinical Application of the Rorschach Test, by Ruth
Bochner and Florence Halpern. New York: Grune &
Stratton, 1945. $4.00.

Clinical Electrocardiography, by David Scherf, M.D., and
Linn J. Boyd, M.D. 2d ed. Philadelphia: J. B. Lippincott
Company, 1946. Pp. 268. $8.00.

Personality Factors in Counseling, by Charles A. Curran.
New York: Grune & Stratton, 1945. Pp. 310. $4.00.

Rorschach’s Test, II. A Variety of Personality Pictures,
by Samuel J. Beck. New York: Grune & Stratton, 1945.
$5.00.

War Neuroses, by Roy A. Grinker and John P. Spiegel.
Philadelphia: The Blakiston Co., 1945. Pp. 145. $2.75.

The 1945 Year Book of General Medicine. Chicago: Year
Book Publishers, Inc., 1945. $3.00.

The 1945 Year Book of Industrial and Orthopedic Sur-
gery. Chicago: Year Book Publishers, Inc., 1946. Pp. 432.
$3.00.

The 1945 Year Book of Pediatrics, edited by Isaac A.
Abt and Arthur F. Abt. Chicago: Year Book Publishers,
Inc., 1946. Pp. 448. $3.00.

Ambulatory Proctology, by Alfred J Cantor, M.D. New
York: Paul B. Hoeber, Inc., 1946. Pp. 524. $8.00.

Oral Medicine, by Lester W. Burket, D.D.S., M.D. Phila-
delphia: J. B. Lippincott Company, 1946. Pp. 674. $12.00.

A Textbook of Gynecology, by Arthur Hale Curtis,
M.D. 5th ed., Philadelphia: W. B. Saunders Company,
1946. Pp. 755, illustrated. $8.00.

Surgical Treatment of the Nervous System, edited by
Frederic W. Bancroft, M.D., F.A.C.S., and Cobb Pil-
cher, M.D., F.A.C.S. Philadelphia: J. B. Lippincott Com-
pany, 1946. Pp. 534, illustrated. $18.00.

The 1945 Year Book of General Therapeutics, edited by
Oscar W. Bethea, M.D., F.A.C.P. Chicago: Year Book
Publishers, Inc. Pp. 456. $3.00.

North Dakota State Medical Assn.

Dr. A. E. Spear, Pres.

Dr. Philip G. Arzt, Pres. -Elect
Dr. L. W. Larson, Secy.

Dr. W. W. Wood, Treas.

North Dakota Society of
Obstetrics and Gynecology
Dr. E. H. Boerth, Pres.

Dr. Paul Freise, Vice Pres.

Dr. G. Wilson Hunter, Secy .-Treas.

Minneapolis Academy of Medicine
Dr. Karl W. Anderson, President
Dr. Russell W. Morse, Vice Pres.

Dr. J. C. Miller, Secretary

Dr. Ragnvald S. Ylvisaker, T reasurer

Dr. Henry E. Hoffert, Recorder

ADVISORY COUNCIL

South Dakota State Medical Assn.
Dr. F. S. Howe, Pres.

Dr. H. R. Brown, Pres.-Elect
Dr. J. L. Calene, Vice-Pres.

Dr. Roland G. Mayer, Secy .-Treas.

South Dakota Public Health Assn.
Dr. J. M. Butler, Pres.

Dr. C. E. Sherwood, Vice Pres.
Dr. Gilbert Cottam, Secy. -Treas.

Sioux Valley Medical Assn.

Dr. D. S. Baughman, Pres.

Dr. Will Donahoe, Vice Pres.

Dr. R. H. McBride, Secy.

Dr. Frank Winkler, Treas.

BOARD OF EDITORS

Dr. J. A. Myers, Chairman

Montana State Medical Assn.

Dr. S. A. Cooney, Pres.

Dr. M. A. Shillington, Pres.-Elect
Dr. R. F. Peterson, Secy .-Treas.

N orthwestern Pediatric Society
Dr. G. B. Logan, Pres.

Dr. Geo. Kimmel, Vice Pres.

Dr. Northrop Beach, Secy. -Treas.

Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.

Dr. R. C. Webb, Secy. -Treas.

American Student Health Assn.

Dr. Ralph I. Canuteson, Pres.

Dr. Glenadine Snow, Vice Pres.

Dr. G. T. Blydenburgh, Secy. -Treas.

Dr J . O. Arnson
Dr. A. B. Baker
Dr. D. S. Baughman
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W. A. Fansler

Dr. A R. Foss
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. L W. Larson
Dr. W H Long
Dr. O. J . Mabee

Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C. H. Nelson
Dr. N. J . Nessa
Dr. Martin Nordland
Dr. L C. Ohlmacher
Dr. K A. Phelps
Dr. C. E. Sherwood

Dr. M. A. Shillington
Dr J. C. Shirley
Dr. E. Lee Shrader
Dr. E. I . Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. W P. Smith
Dr. S. E. Sweitzer

Dr W. H. Thompson
Dr E. L. Tuohy
Dr M. B. Visscher
Dr. O. H Wangensteen
Dr. S. Marx White
Dr. H M N Wynne
Dr. Thomas Ziskin,
Secretary

LANCET PUBLISHING CO., Publishers, 84 South Tenth Street, Minneapolis 2, Minnesota

Minneapolis, Minnesota, June, 1946

MEDICAL CONVENTIONS AGAIN

Medical conventions have now returned to their pre-
war splendor. They were few in numbers and the pro-
grams sadly curtailed during the war years that are now
fortunately past.

The North Dakota Medical Association held its an-
nual meeting at Bismarck May 16-18. The Minnesota
State Medical Association met in St. Paul May 20-22.
The annual meeting of the South Dakota Association
is scheduled for June 1-4 in Aberdeen. The Montana
Association will meet in Great Falls July 18-20. Al-
though these state associations suffered some abbrevia-
tions in program and attendance during the war period,
their sheltered locations in the very heart of the nation
gave their meetings some advantage over those that were
not so favorably situated. The national associations were
hit the hardest, not only because of the undesirability
of meeting in cities on the Atlantic or Pacific coast, but
also because of restricted transportation facilities and

actual government orders prohibiting attendance at any
such gathering beyond a certain limited number that
seemed necessary to transact business and keep the or-
ganization intact.

There is ever increasing interest manifested in social
and medical economic problems. Sane, progressive groups
have done splendid work to institute justice in place of
charity; and effort is being made to level out the eco-
nomic burden of unpredictable illness. A well thought
out prepayment medical care plan was approved by the
Minnesota Association.

The commercial exhibits are more popular than ever.
The old-time detail man with his stereotyped lecture has
been superseded by a specialist in his line who is truly
qualified to dispense information on modern therapy.
Fie does so in a way that really appeals to physicians,
who have a right to feel confused by the multiplicity
of products and proprietary names that have come into
the market during the past few years. A. E. H.

199

200

The Journal Lancet

DOCTORS ARE STILL SCARCE

The latest available count of physicians in the United
States reaffirms the complaints of scarcity that have
been made in the past few years, especially in the less
populous states that make up the greater part of the
Journal Lancet’s primary constituency.

Of the four states — Minnesota, Montana, North
Dakota, South Dakota — represented, Minnesota has by
far the largest number of physicians, namely, 2565. Of
these all but approximately 250 are under 69 years of age.
General practitioners in the state number 1500; those
under 69, 1208. Interns number 65 and hospitals 286.

Montana has a total of 361 physicians, of whom all
but 57 are under 69 years of age. Of the total, 201 are
general practitioners, of whom 154 are under 69. Like
the Dakotas, Montana has no interns, though it has
79 hospitals.

North Dakota has 363 physicians, of whom 69 are
over 69 years of age. About two thirds of the total,
or 202, are general practitioners, and 155 of these are
under 69 years of age. The state has 64 hospitals.

South Dakota has only 334 physicians, of whom 61
are over 69 years of age. About two thirds, or 200, are
general practitioners, and some three fourths, or 153,
are under 69 years of age. The state has 73 hospitals.

These figures compare with a total of 118,338 physi-
cians in the United States, of whom 101,555 are under
69 years of age; a total of 67,664 general practitioners,
of whom 56,122 are under 69 years of age; and a total
of 6616 interns and 8258 hospitals.

Of the specialists, surgeons are by far the largest
group; they number 12,488. Next in order are the in-
ternists, with 4926; the eye, ear, nose, and throat spe-
cialists, with 4258; the pediatricians, with 3724; and the
obstetricians and gynecologists, with 3677. Between this
group and the next largest, the urologists, with 1985,
there is a considerable drop. Smallest of the groups are
the plastic surgeons, who number 85.

French Doctors Want Automobiles

Doctors in at least eighteen Departments of France
have refused to sign birth or death certificates in protest
against the Government’s failure to meet their demands
for automobiles, according to a cable to The New York
Times. The "strike” is threatening to spread over the
whole of France. A commission formed by the Ministry
of the Interior thus far has failed to reach a solution
acceptable to the doctors’ organizations, which, according
to a report in Figaro, have received only 200 automobiles
since the beginning of the year, despite urgent demands
for 3000.

. . . fUEET OUR COflTRIBUTORS . . .

Dr. Halward M. Blegen of the active surgical staff
of the Western Montana Clinic and St. Patrick’s Hos-
pital at Missoula, Montana, is a graduate of the Univer-
sity of Minnesota (B.S., B.M., 1936, M.D., 1937). He
is a Fellow of the American College of Surgeons, a Di-
plomate of the American Board of Surgery, and a Fellow
of the American Medical Association and the Montana
State Medical Association.

Dr. Esther L. Boyer, a surgeon, also of the Western
Montana Clinic at Missoula, Montana, is a graduate of
the University of Wisconsin, with the degrees of B.A.,
M.A., Ph.D., and M.D. Before going to the Missoula
clinic she was Instructor in Anatomy at the Women’s
Medical College of Pennsylvania in Philadelphia ( 1940—
42), and Instructor in Surgery and Student Health Phy-
sician at the University of Missouri Medical School
( 1942-44) . She is a member of Sigma Xi, the American
Association of Anatomists, and the Montana State Med-
ical Association.

Dr. Sidney Granville Clayman, whose specialties
are tuberculosis and diseases of the chest, has been at
the State Tuberculosis Sanatorium, San Haven, North
Dakota, as staff physician in charge of male patients,
for the past five years. He is a graduate of the Univer-
sity of Michigan Medical School (M.D., 1939), and a
member of the American Medical Association, the Tru-
deau Society, and the American College of Chest Physi-
cians.

Dr. Stuart Lane Arey, who was also a contributor
to our May issue, is a Minneapolis pediatrician.

Dr. Ellis Herndon Hudson, recently Officer in
Charge of Preventive Medicine, Department of Hawaii,
has returned to Ohio University at Athens as Director
of Student Health. An authority on nonvenereal syph-
ilis, he spent many years in the Near East before assum-
ing the position at Athens. At the beginning of the war
he was assigned as Captain of the Medical Corps,
U.S.N.R., in charge of the Bethesda Navy Tropical Dis-
ease Laboratory and Tropical Disease Wards. His teach-
ing and preparation of text pamphlets on tropical dis-
eases were a significant contribution to the medical as-
pects of the war. He holds the Certificate in Tropical
Medicine of the London School of Tropical Medicine.

Dr. Joe W. Baird, Associate Professor of Anesthesiol-
ogy at the University of Minnesota, is a graduate of the
University of Nebraska (B.Sc. in Med. and M.D.,
1930). He was resident at Hartford (Connecticut) Hos-
pital from 1940 to 1942 and did graduate work at the
Mayo Clinic 1942-43. He is a Diplomate of the Amer-
ican Board of Anesthesiology and a member of the
American Medical Association, the American Society of
Anesthetists, and the Hennepin County Medical Society.

June, 1946

201

MEET OUR CONTRIBUTORS (Continued)

Dr. Robert E. Van Demark, orthopedic surgeon
with the Army for the past several years, is now Chief
of the Orthopedic Section, Regional Hospital, Camp
Joseph T. Robinson, Arkansas. He is a graduate of
Northwestern University (M.B., 1938, M.D., 1939),
and of the University of Minnesota. He is a member
of the Minnesota State Medical Association and the
Olmsted Houston Fillmore-Dodge County Medical So-
ciety and a Fellow of the American Medical Association.

ANNOUNCEMENTS

American College of Chest Physicians

Owing to crowded conditions in San Francisco hotels,
the dates of the 12th Annual Meeting of the American
College of Chest Physicians have been changed from
June 29-30, July 1-2 to June 27-30.

National Gastroenterological Association

The National Gastroenterological Association resumes
its annual scientific sessions this year with a three-day
convention in New York City, June 19-21. The pro-
gram will consist of five symposia and five additional
short papers. There will be two luncheon round-table
conferences, one on June 19, on "Parasitology and Trop-
ical Medicine from a Military and Civilian Standpoint,”
led by Dr. Z. Taylor Bercovitz, and the other on June
21 on "Socialized Medicine,” led by Dr. William B.
Rawls. A symposium on "Carcinoma of the Gastrointes-
tinal Tract” will be presented by Dr. George T. Pack
and his associates from the Memorial Hospital, New
York.

American Association for the Study of Goiter

The American Association for the Study of Goiter
will hold its annual meeting at the Drake Hotel, Chi-
cago, June 20—22. Among the program participants are
Dr. J. W. Buchta of the University of Minnesota, who
will speak on "Radioactive Isotopes,” and Dr. Brown W.
Dobyns of Rochester, Minnesota, who will read his
Van Meter Prize Award essay.

125 Fellowships in Public Health

Surgeon General Thomas Parran announces a grant
for the establishment of 125 fellowships to train physi-
cians and sanitary engineers in public health, approved by
the National Foundation for Infantile Paralysis. Each
fellowship provides a year’s graduate training in a school
of public health or a school of sanitary engineering. The
fellowships will be available for the academic year
1946—47 or 1947-48, and are open to men and women,
citizens of the United States under 45 years of age.

The purpose of the fellowships is to aid in the recruit-
ment of trained health officers, directors of special med-

ical services, and public health engineers to help fill some
of the 900 vacancies in public health medical positions
and 300 vacancies for public health engineers, existing
in state and local health departments over the country.
The fellowships are reserved for newcomers to the public
health field, and are not open to employees in state and
local health departments.

Applicants may secure details by writing to the Sur-
geon General, U. S. Public Health Service, Attention
Public Health Training, 19th and Constitution Avenue
NW., Washington 25, D. C. The awards committee
will act on applications on June 15, July 1, July 15, and
August 1.

" Rheumatism” Resumes Publication

Rheumatism, quarterly journal devoted to the clinical
aspects and treatment of rheumatic disorders, resumed
publication in April 1946, after suspension of publica-
tion since 1940, owing to war conditions. The journal,
sold on subscription of 10 shillings p>ost-free to the med-
ical profession only, is published by the Rolls House
Publishing Company, Ltd., 2 Breams Building, London,
E. C. 4, England.

Scholarships for Advanced Study of
Eye Diseases

Announcement has been made of four scholarships for
the advanced study of eye diseases at New York Uni-
versity College of Medicine, to be provided annually by
the Lions Club of New York. They will be awarded
to graduate medical students selected by the department
of ophthalmology of the university. In accepting the
gift Dr. Currier McEwen, dean of the College of Medi-
cine, pointed out that it fitted into the plan for an In-
stitute of Eye Disease to be established as part of the
great new medical center which will unite New York
University College of Medicine and Bellevue Hospital.

Journal of Kansas Medical Society
Names New Editor

W. M. Mills, M.D., editor of the Journal of the
Kansas Medical Society for the past eleven years, re-
signed from the editorship in April to assume his new
duties as president of the Kansas Medical Society.

Dr. Mills has been succeeded as editor by Lucien R.
Pyle, M.D., of Topeka, who has been a member of the
editorial board of the Journal for eleven years. Dr. Pyle
continued his editorial work during the four years he
served with the Navy, and the Journal considers him well
qualified for his new position. He assumed his duties
with the May issue.

202

The Journal Lancet

^beailvi

Dr. Donald Michael De Courcy, 44, St. Paul,
died May 28 after a heart attack, an hour before his
second son was born. Dr. De Courcy, a graduate of
Marquette University School of Medicine, attended St.
Thomas College and the University of Minnesota. He
was formerly a national collegiate tennis champion and
captain of the St. Thomas football team, and is one of
three hockey players listed in the Marquette University
Hall of Fame.

Dr. Jesse E. Long, 87, of Minneapolis, died April 30.
A graduate of Rush Medical College in 1882, Dr. Long
had practiced in Minneapolis for 52 years, and retired
only a few years ago. He was one of the oldest mem-
bers of the Hennepin County Medical Society.

Dr. John Henry Noonan, 64, of Anaconda, Mon-
tana, died May 9 in that city, following an illness of two
months. Dr. Noonan, a graduate of Northwestern Uni-
versity Medical School (1908), had practiced in Ana-
conda for 29 years. He was born in Kokomo, Indiana,
in 1882.

Dr. Samuel Rainville, 71, physician at Crosby,
North Dakota, for more than 30 years, died there
May 1, in his sleep, after a heart attack. A native of
Glens Falls, New York, where he was born December 25,
1874, he was brought to Minneapolis to live as a small
boy and later moved to Devils Lake, North Dakota,
where he was a member of the first high school grad-
uating class. He was a graduate of the Minneapolis
College of Physicians and Surgeons (1897), and had
practiced at Leeds and Minnewaukan, North Dakota,
and later near Spokane, and, again in North Dakota,
at Bowbells and Kenmare before moving to Crosby in
1915. He is survived by his wife and two daughters.

Dr. Cyril A. Schwarze, 32, of Rochester, Minne-
sota, son of Mr. and Mrs. Arthur Schwarze of Cassel-
ton, North Dakota, died April 22 at Rochester. Dr.
Schwarze was born in Chaska, Minnesota, and was a
graduate of the University of Wisconsin Medical School
(1938). Dr. Schwarze interned at the Methodist Hos-
pital, Des Moines, Iowa, and for a time was on the
staff of Bradley Memorial Hospital, Madison, Wiscon-
sin. He served overseas as a captain in the Army Med-
ical Corps.

Dr. Jacob Martin Erman, 54, of Omaha, Nebraska,
a native of Minneapolis and a resident there for twenty-
five years, died in Omaha June 4 of a heart attack. He
was a graduate of the Chicago College of Medicine and
Surgery, class of 1916.

Dr. Roger H. Mattson, 56, long a practicing physi-
cian in North Dakota, died June 5 at Bayport, Minne-
sota. Services will be at New Rockford, North Dakota.
He was a graduate of the University of Minnesota Med-
ical School, class of 1920.

Views Items

NEWS FROM MINNESOTA

Minnesota State Medical Association. About 300 per-
sons were present at the opening session of the associa-
tion, which met May 20-22 in St. Paul. Among the
many topics discussed were advances in surgical treat-
ment of cancer of the pancreas, brucellosis, bacillary
dysentery, the Rh factor, and the use of hormone prepa-
rations.

In his presidential address Dr. Edwin J. Simons of
Swanville said: "Unless every physician and every med-
ical society devotes more time to the proper, broad solu-
tion of medicine’s problems, the majority of the entire
profession’s time will be spent filling out governmental
reports under a new national compulsory health insur-
ance program.”

The establishment of a voluntary prepaid medical serv-
ice plan for Minnesota was authorized by the association.
The action was announced by Dr. B. J. Branton, Will-
mar, chairman of the committee on organizing for pre-
paid medical care.

A colorful feature of the meeting was the presenta-
tion of 50-Year Club pins to nine Minnesota physicians
who have practiced in the state for fifty years. Dr.
L. E. Claydon of Red Wing, Dr. E. E. Novak of New
Prague, and Dr. M. F. Knauff of St. Paul were present
at the dinner honoring the 50-year men. Those absent
from the celebration were Dr. Charles Bolsta, Orton-
ville; Dr. Charles Germo, Balaton; Dr. Charles D.
Harrington, Wayzata; Dr. A. E. Henslin, Le Roy; Dr.
Edgar A. King, Minneapolis; and Dr. George P. Kirk,
East Grand Forks.

Dr. William A. Coventry of Duluth, past president
and now speaker of the House of Delegates, was hon-
ored with the distinguished service medal of the asso-
ciation.

Dr. Kano Ikeda, St. Paul, won first prize for a scien-
tific exhibition, presented by the Southern Minnesota
Medical Society, for his display on routine color pho-
tography.

Newly elected officers of the association who will take
over their offices on January 1, 1947, are: Dr. L. A.
Buie, Rochester, president; Dr. Carl B. Drake, St. Paul,
vice president; Dr. L. E. Gowan, Duluth, vice president;
Dr. B. B. Souster, St. Paul, secretary; Dr. W. A. Cov-
entry, Duluth, speaker, House of Delegates; Dr. Charles
G. Sheppard, Hutchinson, vice speaker; Dr. F. J. Elias,
Duluth, chairman of the Council.

Dr. Gaylord W. Anderson, Director of the School
of Pubilc Health, University of Minnesota, has been
elected Secretary-Treasurer of the Association of Schools
of Public Health.

The Minnesota Hospital Association held its 23d
annual convention May 26-28 in St. Paul. Twelve allied
organizations, some of which held separate meetings,
attended the convention. A dinner at St. Joseph’s Hos-

June, 1946

203

of postgraduate medical education at the University of
Minnesota. At a luncheon meeting on May 27 George
Bugbee, executive director of the American Hospital
Association, spoke on "Federal Legislation Affecting
Hospitals.”

The Renville County Board of Commissioners has
selected Carl H. Buetow of St. Paul as the architect for
the new county hospital. Browns Valley is considering
the design for its proposed hospital submitted by Ursa
Louis Freed of Aberdeen, South Dakota. Fairfax is
considering the question of whether a county hospital is
needed.

The Grand Chapter of Alpha Epsilon Iota, national
women’s medical group, held its meeting in Minneapolis
May 1-3. The sorority, formed in Ann Arbor in 1940,
now has 26 chapters in medical schools throughout the
country, with a membership of 3000, including doctors
and undergraduate women medical students.

The St. Paul Surgical Society observed its tenth anni-
versary April 26 at a dinner meeting. Dr. Robert L.
Sanders of Memphis, Tennessee, spoke on "Surgical
Complications of Duodenal Ulcer.” Guests included
Dr. Owen H. Wangensteen of the University of Min-
nesota, Dr. Robert McGancy, president of the Minne-
apolis Surgical Society, and a group of Mayo Clinic sur-
geons.

Minneapolis physicians who have returned from mili-
tary service to resume practice include Drs. George S.
Bergh, Gordon G. Bowers, Cyril P. Dargay, Samuel A.
Dworsky, Nathan K. Jensen, Bourne Jerome, John P.
Kelly, Karl W. Pleissner, Erven E. Pumala, and Rich-
ard E. Reiley.

Dr. Donald Paulson, formerly of St. Paul, is credited
with saving the life of a Texas soldier who had been
stabbed in the heart. Dr. Paulson performed a delicate
emergency operation, involving drawing the heart from
its sac and reviving it with injection of adrenalin and
hand massage. Hospital authorities described the odds
against the success of the operation as greater than
100 to 1. Dr. Paulson was graduated from the Uni-
versity of Minnesota Medical School in 1937.

Dr. F. M. Feldman, city health officer of Rochester,
speaking before the Rochester and Olmsted County
Safety Council in April, pointed out that health depart-
ments must in future concentrate more on preserving
the health of older persons, of whom there will be an
increasing number. Figures compiled by health agencies
show that in 1955 Minnesota will have a definite and
marked increase in the 60 to 75 age group, which is
expected to increase by 135,000, so that one person in six
in the state will be over 60.

In the Elias P. Lyon memorial lecture delivered before
350 scientific research workers at the University of Min-
nesota in May, Dr. Carl F. Cori of Washington Uni-
versity stated that research has discovered a lead to the
effect of insulin on the energy-producing functions of
the body. The data are expected to be of importance
in long-range studies of the interrelations of insulin and
other hormones.

Dr. Mario Fischer, city health director of Duluth, has
been named a member of a health advisory group assist-

ing the Minnesota Committee of Local Health Services.
Such groups are being organized also in Willmar, Vir-
ginia, Hibbing, and Ely. They will urge legislative
action to permit multiple-county health districts.

The Veterans Administration for the five-state area
including Minnesota, the Dakotas, Iowa, and Nebraska,
will have a board of physicians acting as consultants to
Dr. Einer Andreassen, acting VA medical director.
Among the physicians already appointed as chief consult-
ants are Dr. Alan Challman, Minneapolis, neuropsy-
chiatry; Dr. Everett K. Geer, St. Paul, tuberculosis; Dr.
Russell H. Frost, Minneapolis, tuberculosis (to serve
full time) ; Dr. Robert R. Kierland, Rochester, dermatol-
ogy; and, from the Mayo Clinic, Dr. Oscar T. Clagett,
thoracic surgery; Dr. Thomas B. Magath, pathology,
and Dr. Winchell McK. Craig, neurosurgery.

The Minneapolis Council of Social Agencies is con-
ducting a study of city health problems through its
health and medical care division, of which Dr. Donald
A. Dukelow is director. The five-point initial program
includes a study to determine the advisability of creating
a bureau of industrial health; an inquiry into the need
of developing an extensive program of public health den-
tistry for children; a long-term plan for the institutional
care of chronic and convalescent cases; advisory studies
in regard to a proposed bill for a state enabling act to
permit multiple-county health districts; establishment of
uniform methods of record keeping and reporting of
social and medical information at medical care insti-
tutions.

Dr. Arthur George Davis, orthopedic surgeon, ad-
dressing a group attending a continuation course spon-
sored by the University of Minnesota and the Hennepin
County Medical Society, said that spine injuries in the
region of the neck often go undetected, and conditions
that stem from the hurt may be diagnosed as symptoms
of another injury or infection. Dr. Davis, staff chief
at Shriners Hospital for crippled children in Philadel-
phia, served as a wartime consultant on orthopedics to
the Army.

Hospital leaders of Duluth paid tribute early in May,
at the annual observance of Hospital Day, to the volun-
teer hospital and nursing workers who gave unstinting
service during the critical war years and are continuing
their help in the postwar period, while hospitals are still
struggling to maintain adequate service with limited
space and personnel.

Dr. Edward N. Peterson, Virginia physician and sur-
geon, has been named chairman of the St. Louis County
Republican party.

Raymond K. Runge, X-ray technician at the Mayo
Clinic, has been elected president of the Minnesota
Society of X-Ray Technicians.

With the slogan "A Better City through Better
Health,” Minneapolis conducted a public health week
beginning May 20, sponsored by the Junior Chamber
of Commerce and the City Health Department. A radio
forum was conducted each day, with special speakers,
and an information booth was maintained in the Medical
Arts Building. Health subjects discussed included child
health, venereal disease prevention, blood banks, and

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The Journal Lancet

food sanitation. Among the speakers were Dr. Frank J.
Hill, city health commissioner, Dr. William A. O’Brien
of the University of Minnesota, Dr. E. J. Huenekens,
chairman of the mayor’s advisory committee on health,
and Dr. Hermina Hartig, public school physician.

According to the Minnesota State Medical Associa-
tion, ten Minnesota towns — Brandon, Browns Valley,
Canton, Evansville, Henderson, Lewisville, Madison
Lake, Menagha, Northome, and Sanborn — are still
without doctors. In the summer of 1945, at the peak
of the doctor-dentist shortage, about forty towns had
neither a dentist nor a doctor. Physicians are said to be
returning at a faster rate than dentists. Approximately
1200 doctors, of the 2800 practicing in the state when
the war began, left for military service.

A grateful patient, Eddie Barnes of Fairmont, a dis-
abled veteran of World War I, has established "the
Dr. H. B. Bailey Memorial Fund,” in honor of the
physician who devoted many hours to helping him.
Mr. Barnes, who conducts a magazine subscription and
greeting card business from his home, plans to set aside
5 per cent of his profits on subscription sales and 10
per cent on greeting card sales. "It will not be much,”
remarks Mr. Barnes, as reported in the Austin Daily
Herald, "but just a few dollars would give someone a
bedside telephone or radio, a favorite book or magazine,
any one of dozens of little things to make living more
tolerable. It is a work Dr. Bailey would like to have
associated with his memory, for truly he was one who
went about doing good.” The death of Dr. Herbert Burr
Bailey on February 11 was noted in the March Journal
Lancet.

Dr. Karl Pfuetze, medical director and superintendent
of the Mineral Springs Sanatorium at Cannon Falls,
held a chest clinic at the Visiting Nurse’s office in Fari-
bault on May 20.

Dr. George Morris Curtis, professor of surgery at
Ohio State University, spoke at the annual dinner of
the St. Paul Surgical Society and Ramsey County Med-
ical Society in St. Paul on May 20. Dr. Curtis, who
has been directing studies in the relation of iodine to
thyroid activity, predicted that revolutionary changes in
medicine, similar to those caused by the introduction of
X-ray fifty years ago, may result from research now
under way.

TB news. According to Dr. Lewis S. Jordan, presi-
dent of the Minnesota Public Health Association and
president of Riverside Sanatorium at Granite Falls, some
12,000 pupils in 240 schools of four western Minnesota
counties have been given tuberculin tests recently. The
counties are Renville, Yellow Medicine, Chippewa, and
Lac Qui Parle. Among the 12,000, Dr. Jordan said,
not more than 2 per cent were reactors, and in 183
schools not a single child reacted. Awards of tuberculosis
control certificates were made to 106 schools of the four
counties by the American School Health Association.

Dr. Hilbert Mark, Minneapolis, State Health Depart-
ment tuberculosis control officer, spoke at the 27th an-
nual meeting of the Tuberculosis and Health Associa-
tion of St. Louis County at Duluth, on April 16.

Cold Spring, granite community west of St. Cloud,
conducts a tuberculosis control campaign among its em-
ployees. New applicants for employment are given a
complete physical examination, including tuberculin test
and X-ray examination.

Glen Lake Sanatorium has contracted with the Vet-
erans Administration to provide care for 125 veterans of
World War II who are suffering from tuberculosis.
With its present 400 patients, the additional 125 vet-
erans will bring the sanatorium population to an all-time
high, according to Dr. E. S. Mariette, superintendent.
The rate at which the veterans can be admitted will
depend upon how soon an extra 25 nurses can be found.

NEWS FROM MONTANA

Montana physicians who have recently returned from
the services to resume practice include: Dr. R. D.

Harper, Sidney; Dr. D. S. MacKenzie, Jr., Havre;
Dr. L. T. Krogstad, Wolf Point; Dr. R. C. Kane,
Butte; Dr. W. F. Morrison, Missoula.

Dr. W. A. McCannell has moved from Harlem to
Chinook, Montana, where he has taken over the prac-
tice of Dr. D. J. Almas. Dr. Almas is now associated
with Drs. Lawson, Houtz, and McKenzie at Havre.

Dr. Robert A. Benke has moved from Chester to
Kalispell, where he will be associated in practice with
Dr. F. B. Ross.

Dr. Roger Anderson, orthopedic surgeon of Seattle,
addressed a meeting of the Silver Bow County Medical
Society on April 23 on methods of reducing fractures.
There were many guests from surrounding towns, includ-
ing Anaconda and Helena.

The Cascade County Medical Society met at the Rain-
bow Hotel in Great Falls May 10 to discuss plans for
the Montana State Medical Association meeting to be
held July 18—20 in Great Falls.

Dr. Edward S. Murphy of Missoula was awarded the
United States Typhus Commission medal at Fort Mis-
soula on May 13. Dr. Murphy served with the Army
Medical Corps for several years, both in the United
States and the European theater.

Dr. H. D. Harlowe has joined the Garberson Clinic
of Miles City as eye, ear, nose, and throat specialist,
according to Dr. J. H. Garberson. Dr. Harlowe, a
graduate of the University of Minnesota Medical
School, has recently been released from the Army Air
Corps with the rank of Major.

Dr. Arthur Rikli, formerly assistant surgeon with the
U. S. Public Health Service in Washington, D. C., has
been appointed the first director of the newly-created
tuberculosis control division of the Montana State Board
of Health. He will receive from Dr. E. M. Larson of
Great Falls, president of the Montana Tuberculosis
Association, a fully equipped mobile X-ray unit for state-
wide diagnosis. The new X-ray unit, purchased by the
Tuberculosis Association, and equipped to permit 250
examinations daily, will be used to give examinations
without charge at state institutions, to state industrial
workers, and in local communities, in that order. A tech-
nician and a nurse will accompany the unit. Dr. Rikli,

June, 1946

205

a graduate of the University of Illinois Medical School,
interned at Cleveland City Hospital.

Dr. John A. March of Livingston has left for Con-
rad, where he will establish a practice. Dr. March was
for some time associated in practice with the late Dr.
Paul L. Greene.

Dr. L. J. Salan, formerly of Washington, D. C., has
arrived in Conrad to become associated with Dr. W. F.
Paterson.

Dr. Emmet Doles, formerly of Fort Benton, is now in
Chicago, where he holds a three-year residency in radi-
ology and X-ray at Wesley Memorial Hospital.

Seven candidates have been admitted to medical prac-
tice in Montana after board examination, according to
Dr. Otto Klein, secretary of the State Board of Medical
Examiners. They are: James J. Bulger, Helena; Robert
W. Kullberg, Cut Bank; Matthew W. A. Calvert,
Laurel; George J. Moffitt, Deer Lodge; George A. Sex-
ton, Great Falls; James O. Logan, White Sulphur
Springs; T. L. Lockridge, Whitefish. Other candidates
were admitted on a reciprocity basis with other states.

NEWS FROM NORTH DAKOTA

The North Dakota State Medical Association. The
state association, meeting at Bismarck May 26-28, for
their 59th annual session, took two important steps to
improve medical service in the state. The House of
Delegates approved the plan proposed by the Veterans
Administration for permitting veterans to secure med-
ical treatment from physicians of their own choice in
their home communities. A Bismarck office will be estab-
lished to carry out the administration of the plan. Also
approved was the North Dakota Physicians’ Service, a
doctor-controlled prepaid medical insurance plan, offer-
ing surgical, obstetrical, and fracture care to individuals
and groups for small monthly payments.

The new officers elected by the association are: Dr.

A. E. Spear, Dickinson, president; Dr. Philip G. Arzt,
Jamestown, president-elect; Dr. W. A. Liebeler, Grand
Forks, first vice president; and Dr. W. A. Wright,
Williston, second vice president.

Re-elected officers are: Dr. John H. Moore, Grand
Forks, speaker of the House of Delegates; Dr. L. W.
Larson, Bismarck, secretary; and Dr. W. W. Wood,
Jamestown, treasurer. Dr. A. P. Nachtwey, Dickinson,
was named delegate to the American Medical Associa-
tion in 1947, and Dr. G. W. Toomey, Devils Lake,
alternate delegate.

Nominated for the State Board of Medical Exam-
iners, to which appointments are made by the governor,
were: Dr. D. J. Halliday, Kenmare; Dr. Joseph Sork-
ness, Jamestown; and Dr. George M. Williamson,
Grand Forks.

The North Dakota Health Officers’ Association, meet-
ing in Bismarck May 27, heard addresses by Dr. Jay
Arthur Myers, Minneapolis, and Dr. William M. Smith
of Bismarck, director of the Division of Preventable
Diseases of the State Health Department.

Dr. Myers pointed out that tuberculosis takes about
55,000 lives annually, and said: "We can control it if

we carry out what we know.” He said that any effective
tuberculosis control program should include both tuber-
culin tests and X-ray examination, since tuberculin tests
detect the disease in its early stages, whereas about
90 to 95 per cent of those recently infected are missed
if X-rays are used alone.

Dr. Smith discussed North Dakota’s immunization
program, and urged immunization of preschool, grade
school, and high school children against diphtheria and
smallpox.

The North Dakota Radiological Society, also meeting
in Bismarck in connection with the state association
session, heard Dr. Leo Rigler of the University of Min-
nesota speak on lung tumors. Dr. Rigler led a round
table diagnostic conference on May 27, and also ad-
dressed the state association on the early diagnosis of
cancer.

Other speakers at scientific sessions of the state asso-
ciation included Dr. A. W. Adson of the department
of neurosurgery of the Mayo Clinic, who discussed the
early diagnosis of brain tumors. Dr. M. Edward Davis
of Chicago discussed obstetrical emergencies and meno-
pausal bleeding.

Dr. Adson, a member of the Council on Medical
Service and Public Relations of the American Medical
Association, spoke on medical economics at a special
session on May 27.

North Dakota Society of Obstetrics and Gynecology.
The society met at the Patterson Hotel, Bismarck, North
Dakota, on May 26, with Dr. M. Edward Davis of
Chicago as guest speaker. Dr. G. Wilson Hunter, sec-
retary-treasurer, reports the election of the following
officers for the coming year: Dr. Paul Freise, Bismarck,
president; Dr. G. Wilson Hunter, Fargo, vice president;
Dr. F. A. De Cesare, Fargo, secretary-treasurer. Dr.
E. M. Ransom, Minot, was elected to the Board of
Governors for a three-year term. Devils Lake was select-
ed for the November meeting.

The new medical center to be established at the Uni-
versity of North Dakota has the following general ob-
jectives: establishment of a complete medical course at
the university; construction of a university hospital with
a minimum of 200 beds; establishment of a nurses’ train-
ing department; establishment of a department for train-
ing public health personnel; and unification of medical
and health services of the state. John A. Page of the
university faculty is director.

The Grand Forks District Medical Society, meeting
at Grand Forks in April, heard Dr. Bayard Horton of
the Mayo Clinic speak on histamine. Dr. W. C. Dailey
is president of the society.

Dr. Charles B. Porter, formerly of Kentucky, who was
with the 38th Evacuation Hospital in England, Africa,
and Italy during the war, will locate at Crosby.

Dr. Donald W. Fawcett, who in April completed a
month of postgraduate work in pediatrics at Cook

206

The Journal Lancet

County Hospital, Chicago, has resumed practice at
Devils Lake.

Dr. G. J. McIntosh has been renamed city health
officer of Devils Lake.

Dr. Thomas M. Cable, Hillsboro, and Dr. Hugh G.
Cleary, Sharon, have been accepted into membership of
the Traill-Steele Medical Society, at a meeting held at
Mayville in April. Dr. W. H. Cuthbert of the state
hospital staff at Jamestown, formerly of Hillsboro, spoke
on conditions at the Jamestown State Hospital.

The sons of Dr. and Mrs. J. W. Moreland of Carpio
held a reunion at Grand Forks in April on the occasion
of the arrival of Capt. J. William Moreland of the
Army Medical Corps from California.

Dr. L. Almklov, who has long practiced in Coopers-
town, has scotched a rumor that he intends to leave the
town or to retire.

Dr. R. G. White of Minot, district health officer, has
reported that a mobile X-ray unit will be available about
June 1 in all communities served by the First District
Health Unit.

Hospital News. The North Dakota Hospital Associa-
tion met May 9-10 at Fargo, with more than 75 mem-
bers of hospital associations in the state attending. Dr.
G. F. Campana of Bismarck, state health officer, was
among the speakers.

J. E. Janzen, who served 43 months with the Army
and participated in four major Pacific campaigns, has
been named business manager of Jamestown Hospital.

Pembina County Memorial Hospital has been incor-
porated and has chosen a board of directors and officers.
Over $34,000 has been raised in cash and pledges, and
the organization hopes to raise sufficient funds in 1946
to begin construction in 1947.

NEWS FROM SOUTH DAKOTA

The South Dakota State Medical Association held its
annual session at Aberdeen, June 1-4. News of the
meeting will be published in a later issue of the Journal
Lancet. Dr. F. S. Howe of Deadwood, president-elect,
will take office as president of the association.

As president-elect, Dr. Howe in April appeared as a
witness before the Congressional committee considering
the Wagner-Murray-Dingell bill. Dr. Howe was accom-
panied on his trip to Washington by Mrs. Howe, and
together they visited their son, Dr. John Howe, and
his family in Richmond, Virginia, and their daughter,
Mrs. S. C. Spurdon, and family in New York.

Further doctors appointed by Dr. O. S. Randall, exec-
utive director of the South Dakota Field Army of the
American Cancer Society, to work with their county
commanders as educational directors, include: Dr. Wil-
liam Duncan, Webster, Day County; Dr. F. T. Younker,
Sisseton, Roberts County; Dr. P. R. Scallin, Redfield,
Spink County.

Dr. G. C. Redfield of Rapid City has been appointed
by Gov. M. Q. Sharpe to the State Board of Health
to complete the unexpired term of Dr. L. F. Bartels of

Buffalo, who has left the state to live in Lander, Wy- 1
oming. Dr. Redfield will serve until January 1, 1949.

Dr. F. E. Manning has been honored by citizens of •
Custer for twenty years of practice in that community, ji!
A graduate of Creighton University School of Medicine, 5
Dr. Manning came to Custer from Edgemont on April
25, 1926, as an associate of the late Dr. M. Long. He
has been superintendent of the county board of health
for eighteen of his twenty years in Custer, and county
coroner for seven terms. Dr. Manning is also active in
civic affairs and is reported to be an ardent sportsman
and lover of the outdoors. His son, Dr. Don Manning,
is with the Army, stationed at Greensboro, North Caro-
lina, and his daughter, Mrs. Albert Tripet, lives in
Custer.

News of many South Dakota doctors’ resuming or
transferring their practices has come into the Journal
Lancet office.

Dr. John V. McGreevy, associated with Dr. W. A.
Delaney at Mitchell for nine years, has transferred his
practice to Sioux Falls.

Dr. Robert J. Ogborn is now associated with Dr.
Edwin S. Stenberg at Sioux Falls.

Dr. Walker D. Judkins, who has been affiliated with
the sanatorium at Rapid City for four years, in charge
of the tuberculosis unit, has been transferred to the
Indian Service hospital at Tallihina, Oklahoma. The
sanatorium staff and their guests held a picnic honoring
Dr. Judkins before his departure.

Dr. Hugh D. Patterson, formerly of Brainerd, Min-
nesota, is now assisting Dr. A. P. Peeke in his practice
at Volga. Fie is a graduate of the University of Min-
nesota Medical School.

Dr. Howard R. Wold has begun the practice of medi-
cine and surgery at Sisseton, in association with the Sisse-
ton Clinic.

Dr. F. F. Smith of Emery has opened an office at
Chamberlain.

Dr. John H. Dickinson has located in Canistota,
which has been without a resident physician since the
death of Dr. William E. Dickinson, father of the new
practitioner.

Dr. Mark Williams has located at Conde, and will
carry on his practice at his residence, pending the acquir-
ing and equipping of a building for hospital purposes.
He has disposed of the Linton Hospital. Meanwhile,
Conde Community Hospital has been incorporated as a
nonprofit organization.

Dr. Raymond Grove, ear, nose, and throat specialist,
will practice in Sioux Falls, following his recent discharge
from service.

Dr. Frank Lima, formerly of Mobridge and later of
Hoven Hospital, is now in Babylon, Long Island, New
York, with his family, recuperating from an allergic con-
dition that affected his left eye.

Dr. George McIntosh of Hoven, recently released
from service after four years, will be associated with
Dr. Mark Graeber in Eureka.

207

June, 1946

Dr. Robert M. Ferguson, former director of the Sioux
Falls and Minnehaha County Health Department, re-
sumed that position on May 8, after working since
October 1945 on a nutrition research project at Albany,
Georgia.

Dr. Obel T. Andresen of Canton, associated with the
Diekman Clinic, was married on March 2 to Miss
Bessie Costain, music instructor at the Mitchell High
School. Dr. Andresen served during the war with a
hospital unit in both the African and European theaters.

Dr. Edward Greenough of Letcher, a recent graduate
of Northwestern University Medical School, will interne
at General Hospital in Kansas City.

Lt. Stewart T. Ramsdell, graduate of Washington
University School of Medicine, has begun a four-week
basic training program for reserve medical officers at
Brooke Army Medical Center, Fort Sam Houston,
Texas. He is a son of Mr. and Mrs. C. Stewart Rams-
dell of Flandreau.

Dr. Paul K. Odland, son of the Reverend and Mrs.
Ole M. Odland of Dell Rapids, will intern at Long
Beach, California, following his recent graduation from
Temple University School of Medicine.

Dr. A. W. Hermann of Custer will head the Custer
Rotary Club during the coming year.

Dr. T. H. Proctor was installed in April as head of
the Deadwood Lodge of the Elks.

Hospital News. Subscriptions for a projected hospital
at Chamberlain totaled over $43,000 up to April 7.

Dr. Marvin Lane, formerly of Phoenix, Arizona, will
join the hospital staff at McLaughlin.

Dr. Donald Rayl has joined the staff of St. Mary’s
Hospital, Pierre; a graduate of Johns Hopkins Medical
School, and formerly assistant resident in surgery at the
Hospital for Women of Maryland, Dr. Rayl comes
originally from Sioux Falls.

Lt. Col. Claud Lewis, clinical director at Fort Meade
Veterans Hospital, has been made manager of the hos-
pital, succeeding Lt. Col. Peter A. Peffer, who is being
transferred to Roanoke, Virginia.

Dr. Gilbert Cottam, superintendent of the State Board
of Health, points out that at present no federal match-
ing funds are available for hospital construction in the
states. Most communities in South Dakota, he reports,
plan to build hospitals entirely from private and local
funds. However, a bill now being considered by Con-
gress would allocate $398,000 annually for five years for
hospital construction in South Dakota, if the annual
amount is matched by $277,000 in local and private
funds. Such a plan would make $675,000 a year avail-
able for new hospital construction in the state, with 59
per cent of the cost carried by the federal government.

Dr. Cottam pointed out that communities planning
to build hospitals should determine their needs on the
basis of the hospital survey now in progress under the
direction of the State Health Committee and the State
Board of Health, and warned that groups planning new
structures should be assured of sufficient physicians to
staff the hospital before any building is done.

NEW EXECUTIVE SECRETARY OF NORTH
DAKOTA STATE MEDICAL ASSOCIATION

This is to introduce to our readers Mr. E. Forsythe
Engebretson, the new executive secretary of the North
Dakota Medical Association. He was born March 1,
1915, in Fargo, North Dakota, and attended public
schools there through Far-
go Central High School.

Beginning in 1933, he at-
tended North Dakota Ag-
ricultural College for one
year and two terms. He
entered the University of
Minnesota in 1934 and
graduated in 1939 in Law,
with degrees of B.S. and
LL.B.

Since 1939 he has been
associated with the firm of
Cox & Cox, now Cox, Cox
& Pearce, Fargo, both as
an associate member and a
member. He has been engaged in the general practice
of law since that time with the exception of slightly
more than two years’ service in the United States Navy.
He spent 15 months overseas as Executive Officer and
Commanding Officer of PT 354, in Motor Torpedo
Squadron 25, which operated in the Moratai area and
the Philippines.

His present duties as Executive Secretary of the North
Dakota State Medical Association include the adminis-
trative work for the state association, public relations
work, liaison work with the American Medical Associa-
tion and other nation-wide organizations, and will include
administrative work in connection with the medical sec-
tion of the Veterans Administration.

"SOLO OR SYMPHONY?”

A Consideration of Medical Group Practice for the
Demobilized Doctor

Many returning veteran doctors must establish themselves in
practice for the first time or re-establish old practices. Shall
they strike out alone in private practice, or join with other doc-
tors in group practice? This is exactly the question discussed
in a new pamphlet, "Solo or Symphony?,” issued by the Med-
ical Group Practice Council of Medical Administration Service
of New York City, an organization financed partly by grants
from the Rockefeller Foundation, to enlighten professional men
on problems encountered in this field. Subtitled "Shall the De-
mobilized Doctor Enter Medical Group Practice?,” it is in the
form of letters exchanged between a veteran doctor and Dr.
Kingsley Roberts, head of Medical Administration Service.

A fact not usually recognized, Dr. Roberts points out, is that
American doctors first engage in group practice as interns
attached to hospital staffs. Many may also have worked under
a form of group practice while in the Army.

The doctor who decides to investigate further in the field of
group practice will find a variety of choice that strikingly indi-
cates how existing group practice units have come into being
during the past 20 years in answer to definite needs in Ameri-
can life. There are doctors who practice in groups at medical
schools, in hospital clinics, or in industrial clinics and hospitals
such as Henry Kaiser’s on the west coast. Other doctors be-
long to consumer-administered groups such as Group Health
Association in Washington, D. C. There are large private diag-
nostic clinics like the Mayo Clinic, run by groups of doctors or
by one prominent doctor who takes full responsibility for his
staff. Sometimes the patient pays regular doctors’ fees, some-
times he belongs to an insurance plan that foots the bills. The
doctor may be on salary or be paid by some other means.

208

The Journal Lancet

In this great variety, Dr. Roberts points out, there is one
underlying unity. Group medical practice, the application of
medical science by physicians working with joint equipment
and technical personnel, with a centralized administrative and
financial organization, enables the doctor to practice better
medicine. It raises professional standards, increases quality of
service, facilitates and encourages consultation service, conserves
professional time, and reduces overhead expense. These benefits,
says Dr. Roberts, can be passed on to the patient, and in a
well-administered group practice unit, they are passed on.

He points out that many of the 600 group practice clinics in
the United States arose in the period 1918-1930 because doc-
tors returning from World War I service had discovered they
liked working together and so started their own groups. Today
about 70,000 veteran doctors have had their ordinary routines
torn apart by war. They are at the crossroads of their profes-
sional careers. Hospitals like Presbyterian Medical Center in
New York, medical schools like the New York University Col-
lege of Medicine, are experimenting with group practice in their
clinics. Consumer groups, such as unions, are demanding med-
ical protection for their members. The physician is faced with
adapting his medical practice to our changing social and eco-
nomic order. "Solo or Symphony?” poses his problems and
gives a quick view of what one path, group practice, has to
offer him.

The Medical Group Practice Council consisting of forty-four
members is composed entirely of doctors with two exceptions,
one of whom is Alfred G. Stasel, administrator of Eitel and
Franklin Hospitals and manager of Nicollet Clinic, Minneapolis.

CtasttfUd AduchtUctHiHis

PRACTICE FOR SALE

Active general practice in town of 550 north central
Minnesota, with house-office combination completely mod-
ern, grossing $15,000.00 yearly. Excellent hospital facili-
ties nearby. Prefer sale house-office cash or terms. Pur-
chase of drugs and equipment optional. Address Box
833, care of this office.

PHYSICIAN AND SURGEON WANTED

Cooperstown North Dakota invites inquiry concerning
location open to good physician and surgeon. Prospect
of new thirty bed hospital in near future. Only two doc-
tors in county. For details write, Carl Lingby, Secy.
Commercial Club, Cooperstown, No. Dak.

X-RAY PRACTICE

Exceptional opportunity for X-ray man to establish
himself in town of 4200 population; 10,000 in county:
no other X-ray machine in town or county. Small invest-
ment, on percentage basis. Wiring all in, dark-room
ready; rent free to him. Needed badly. For details
address Box 842, care of this office.

LABORATORY TECHNICIAN WANTED

Wanted: A laboratory technician, preferably regis-

ASSISTANCE AVAILABLE

Aznoe’s, established in 1896, has available a number
of well trained physicians (diplomates of the specialty
boards, industrial physicians and surgeons, general prac-
titioners, psychiatrists, tuberculosis specialists and resi-
dents). For histories write Ann Woodward, Aznoe’s-
Woodward Medical Personnel Bureau, 30 North Michi-
gan Ave., Chicago 2, Illinois.

EXCEPTIONAL OPPORTUNITY

for beginning or established physician to share suite of
offices with another physician or dentist. Individual treat-
ment room or laboratory in new office building located
in very best residential retail section of North Minne-
apolis. Address Box 761 A, care of this office.

AduiAtUds' AHHOUHce*yvVht$

PRECISION CONTACTS EXPANSION PROGRAM

Ptecision Contacts, an associated firm of the N. P. Benson
Optical Company, have taken over the sixth floor of the Gate-
way Bank Building, Minneapolis. Their greatly expanded lab-
oratory facilities will permit an increased production and prompt
delivery. Precision Contacts also maintain a contact lens manu-
facturing laboratory in Los Angeles.

In addition to a new laboratory with latest equipment, a
complete research department is maintained for experimental
work in solution and lens design. Research in contact lens solu-
tions is being carried on with the aid of University of Minne-
sota researchers. Albert L. Anderson is managing director of
Precision Contacts.

W. Fred Allen New Upjohn Sales Director
Donald S. Gilmore, president and general manager of The
Upjohn Company, Kalamazoo, has announced the promotion
of Mr. W. Fred Allen, authorized at a meeting of the board
of directors April 23. He was elected to the board of directors
and named vice president and director of sales, filling the
vacancy created by the death of Emil H. Schellack, sales di-
rector, last February.

Mr. Allen was appointed assistant director of sales on Jan-
uary 1 of this year. Starting as a salesman for The Upjohn
Company in Monroe, Louisiana, under the Kansas City, Mis-
souri, branch, Mr. Allen advanced rapidly through various
supervisory positions in the south and southwest. He was sales
manager of the Dallas, Texas, branch for nine years.

PENICILLIN SODIUM 500,000 UNITS

Burroughs Wellcome & Co. has released Penicillin Sodium
500,000 units in rubber-stoppered aluminum-capped bottles.
The addition of 20 cc. of sterile distilled water or isotonic saline
solution provides a solution of Penicillin containing 25,000
units in each cubic centimeter. This new 500,000 unit strength
offers a number of advantages. The higher concentration pro-
vides greater convenience in dosage, requires less storage space
and the opening of fewer vials, and is more economical.

THE BORDEN AWARDS FOR 1945

These awards established in 1936 to recognize and encourage
outstanding research achievements in the food industry and
related fields are administered by seven professional and scien-
tific associations, and are based upon research reported in public
documents or scientific journals.

Associations which make the selections, and the 1945 re-
cipients: American Chemical Society — Ben H. Nicolet, Senior
Chemist, Bureau of Dairy Industry, Department of Agriculture,
for fundamental investigations in chemistry of milk proteins;
American Dairy Science Association — Genn W. Salisbury, Pro-
fessor of Animal Husbandry at Cornell University, for contri-
butions in the feeding of dairy cattle, and for studies in dairy
cattle breeding, also George M. Trout, Professor of Dairy Man-
ufactures, Michigan State College and Staff, Michigan Agricul-
tural Experiment Station, for studies of effect of homogeniza-
tion on the quality, flavor, and some of the physical and chem-
ical properties of milk; The American Academy of Pediatrics —
Edwards A. Park, Professor of Pediatrics at Johns Hopkins and
Staff of the Johns Hopkins Hospital, for fundamental investi-
gations and research achievements in the causes and treatment
of rickets and for stimulating and fostering the spirit of scien-
tific investigation and inquiry in young physicians in all fields
of medicine.

Also the American Home Economics Association — Mrs.
Bertha Shapley Burke, Associate in Nutrition, Department of
Maternal and Child Health, Harvard School of Public Health,
for studies in prenatal nutrition showing importance of the diet
during pregnancy; The American Institute of Nutrition — Har-
old Hanson Mitchell, Professor of Animal Nutrition, Univer-
sity of Illinois, for fundamental contributions in the field of
human and animal nutrition, and for research on the biological

FOR THREATENED AND HABITUAL ABORTION

In the treatment of habitual abortion, “vitamin E should
be used because it appears to offer great hope in salvaging pregnancies that
would otherwise habitually abort.”* Ephynal Acetate — the Roche vitamin E
preparation (^-tocopherol acetate) — is particularly suitable for the treatment
of habitual and threatened abortion because it is stable, of unvarying potency
and purity, and well tolerated even in large doses and over long periods of
time. Its freedom from side reactions is of signal value in all disorders ame-
nable to vitamin-E therapy. Available in tablets of 3, 10, and 25 mg.

HOFFMANN-LA ROCHE, INC., Roche Park, Nutley 10, New Jersey.

*A. T Hertig & R G Livingstone, New England J. Med., 230: 798, 1944

value of milk protein and the efficiency of calcium utilization;
The Poultry Science Association — Erwin Leopold Jungherr, Pro-
fessor of Animal Pathology, University of Connecticut, for ( 1 )
application of histopathology to poultry diseases and (2) co-
operative work with the federal laboratory at East Lansing,
Michigan, on the leukosis complex. The American Veterinary
Medical Association — Willard Lee Boyd, Chief of the Division
of Veterinary Medicine, University of Minnesota, for research
investigations in bovine pathology and for research achievements
on other diseases of the dairy species.

Previous University of Minnesota award recipients are Leroy
S. Palmer, 1939 (deceased), and William E. Peterson, 1942.
At the University of Wisconsin Edwin B. Hart won in 1941,
Kenneth G. Weckel in 1938, Hugo H. Sommer in 1942, and
Paul H. Phillips and Helen T. Parsons in 1944. In 1937, Amy
L. Daniels of the University of Iowa received one of the first
Borden awards. Up to the close of 1945 there have been 47
awards, each consisting of a gold medal and a thousand dollars.

PARKE DAVIS PRODUCTS

Benadryl, a synthetic chemical compound, is made by Parke,
Davis & Company, Detroit. B-dimethylaminoethyl benzhydryl
ether hydrochloride, exhibiting antihistamine action is used as
an antiallergic and antispasmodic. It is supplied in Benadryl
Kapseals, 50 mg., in bottles of 100 and 1000. Benadryl Elixir
(10 mg. Benadryl in each teaspoonful), in 16 oz. and 1-gallon
bottles.

ABDEC drops of a stable, aqueous multivitamin liquid, each
0.6 cc. containing vitamin A, 5000 units; vitamin D, 10,000
units; vitamin Bi, 1 mg.; vitamin B;, 0.4 mg.; vitamin B«, 1 mg.;
pantothenic acid as sodium salt), 2 mg.; nicotinamide, 5 mg.;
vitamin C, 50 mg., are made by Parke, Davis & Company,
Detroit.

They are employed in the prevention and treatment of vita-
min deficiencies and are particularly useful as a supplement in
infant feeding.

"Abdec drops” are supplied in 15 cc. and 50 cc. bottles
equipped with specially calibrated droppers adjusted to deliver
0.3 cc. or 0.6 cc.

Prompt Estrogenic Action

Menopausal symptoms and other conditions
involving an estrogenic deficiency have been
found to respond rapidly and favorably to this
synthetic estrogen.

Schieffelin BENZESTROL, a non-stilbene com-
pound, is a preparation of high estrogenic activ-
ity and has proved to be desirable because of its
low incidence of untoward side effects.

Schieffelin BENZESTROL is available in tab-
lets of 0.5, 1.0, 2.0 and 5.0 mg., in solution, in
10 cc. vials, 5.0 mg. per cc., and vaginal tablets
of 0.5 mg. strength.

Literature and Sample on Request

Schieffelin & Co.

20 COOPER SQUARE • NEW YORK 3, N. Y.
Pharmaceutical and Research Laboratories

Minneapolis, Minnesota
July, 1946

Vol. LXVI, No. 7
New Series

Massive Hemorrhage from the Upper Digestive Tract

Winfred W. Arrasmith, M.D., F.A.C.P.

Casper, Wyoming

Through the years of clinical experiences with mass-
ive bleeding in the upper digestive tract, I have been
intrigued by the diversity of my cases as to etiology,
symptomatology, and end results.

With a few exceptions I shall hold what follows
largely to my personal experiences gleaned from a rea-
sonably large number of cases of bleeding in the upper
digestive tract. I pledge that my deductions are founded
on a strict basis of originality, and that in no case have
I withheld the bitter from the sweet. Men practicing in
localities similar to the one in which I expend my pro-
fessional efforts, will appreciate the clinical wisdom that
I have gained from these tragic episodes. The prog-
nostic values must obviously vary where the matter of
hospitalization is but a few city blocks distant, as con-
trasted with countless miles through dim trails in the
sagebrush.

Peptic and Duodenal Ulcer
Peptic and duodenal ulcer are, of course, the most
common causes of bleeding in the upper digestive tract
segment. An intensive review of recent literature leads
me to be exceedingly optimistic as to the newer ovations
in the medical treatment of these lesions. Gastroscopy,
amino acid therapy, adjuvant vitamin administration,
and the well recognized aluminum hydrate treatment
offer favorable elements to our armamentarium of thera-
py. Based on observation in my own sphere of practice,
my belief is that peptic ulcer is definitely on the increase.
Perhaps this is answerable in view of the nervous tension
incident to problems of the recent war. Excessive use
of alcohol prevalent in both sexes throughout the war
period is without doubt reflected in increased incidence

Read before the American College of Physicians, Montana-
Wyoming Branch, at Billings, Montana, April 27, 1946.

of upper alimentary lesions. Tobacco, especially smok-
ing, is a definite provocative element in the etiology of
peptic ulcer. I concur fully with the gastroenterologists
of the Lahey Clinic in their positive viewpoint that smok-
ing is a cardinal element of etiology and perpetuation
of active ulcer.

Causative Agents

This paper, therefore, shall be limited to the etiology
and the actual treatment of the immediate and urgent
situation of massive bleeding from the esophagus, the
stomach, and the duodenum. Also some of the recently
recognized sequellae incumbent upon large hemorrhage
occurring in the upper digestive tract will be included.

The literature is copious with factors of etiology in
the matter of such hemorrhage. This presentation will
purposely be restricted to the four most common causes.
In order of frequency, the causative agents are: gastric
and duodenal ulcer; ruptured varices occurring largely
in the esophagus, but not infrequently in the gastric
mucosa; malignancy, either primary or from contiguous
viscera; and with certain limitations, trauma.

Whatever may be the cause of a violent hematemesis
and melena with the accompanying collapse, it is an ex-
ceedingly urgent situation for the patient, the clinician,
and the family. Those who aspire to the clinical field
see these cases sporadically, and too often without fore-
warning. They are serious in that the victim may make
a hasty exodus by the very simple route of exsanguina-
tion. Particularly is such a danger paramount in our
section of the country where physicians, ambulances, and
ultimate hospitalization are available only at great dis-
tances from the patient in his primary episode. In this
category of patients residing in remote sections of my
country is the sheepherder, the cow hand, the oil-field

210

The Journal Lancet

worker and the rancher, all of whom reside far off the
modern highway.

Diagnosis and Treatment

Each case of massive bleeding must invoke superlative
clinical judgment from the original onset through the
entire clinical course of the case. It is rare that the
patient himself, due to his condition, is able to offer an
immediate comprehensive history. Frequently there is
no history of significant import to establish even a pos-
sible diagnosis of the bleeding site. On the other hand,
we are often appraised by the family or associates of
the patient of an ulcer syndrome, or of an alcoholic his-
tory that leads to a strong suspicion of a cirrhotic liver
with complicating ruptured varices at or near the cardia.

Massive bleeding has occurred in my practice in what
one might term an "idiopathic sense.” Trauma from
eating a gargantuan meal has definitely been the primary
etiology of several severe bleeders in my experience.
Their occupational situation was particularly punishing
to the torso, and they bled to the point of collapse.

It is obvious that when large hemorrhage occurs in
the esophagus, stomach or duodenum, greater or lesser
shock prevails. The patient is usually in extremeness.
We can not say that he has, or has not stopped bleeding.
I no longer place any credence in the color, quantity
and character of the vomitus, or the appearance of a
melena in locating the possible site of the accident. Our
first duty is to treat this patient who is either in a
status of shock, or impending shock. It would be super-
fluous to include in this presentation a recapitulation of
the treatment of collapse. For the record, however, I
place oxygen and morphia in the affirmative column of
immediate therapy.

Victims of hemorrhage are too sick for immediate
intensive diagnosis. A trip to the X-ray room and the
ingestion of barium is to be delayed until a reasonable
assurance exists that the bleeding is controlled and all
evidence of collapse has vanished. Surgery on a case in
extremeness, is nothing short of poor clinical judgment.
Too often a capable surgeon in a prolonged bungling
procedure meets defeat in locating the site of bleeding,
and his patient promptly makes an unforgivable exodus.
When and when not to meddle surgically in these cases
is a matter that taxes to the utmost the ability of both
internist and consulting surgeon. I admit that I belong
to the conservative group. Low mortality and early re-
covery in benign lesions have justified my position.

In recent years I have abandoned the viewpoint that
the hematocrit is merely a lazy man’s laboratory pro-
cedure and have utilized this valuable diagnostic aid
especially in the early hours of hemorrhagic tragedy.
This expression of mathematical percentage of ratio
between the volume of red cells per unit of circulating
blood has been of more than usual importance in direct-
ing replacement of hemic deficiency. It is truly an ova-
tion in the field of hematology, and an exceedingly
precious asset in dealing with bleeding in all ramifica-
tions. Whether it be a bleeding ulcer, a severe burn,
metrorrhagia, or even a case of extreme malnutrition;
the hematocrit provides the clinician a superlative index
for therapy.

I subscribe completely and unconditionally to the view-
points of Soper 1 and Meyer 2 that the intravenous sup-
ply of plasma, citrated blood, and physiological solutions,
in large quantities is indicated. The so-called "blowing
out” of a fibrous clot at the lesion by such a procedure
is entirely a myth. Since Soper published his article,
"Hematemesis”,3 in 1931, I have evacuated the accumu-
lated debris from the upper digestive tract by the pass-
age of a Levin tube at frequent intervals, or better still,
by leaving it installed via the nasal route. The removal
of this debris obviates to a minimum the azotemia and
the troublesome gastric contractions, placing the clinician
in a position to appraise at all times the character of the
stomach content. The indwelling tube has been used for
the purpose of early feeding of albumin and gelatin
waters. If the matter of chloride loss might be an indict-
ment to my procedure, the administration of physio-
logical and glucose solutions by clysis amply meets the
challenge.

The early use of the Levin tube is an exceedingly val-
uable aid in the administration of hemostatic agents to
the site of the bleeding. Topical thromboplastin,4 re-
cently made available, has been used by this technique
with admirable results in more recent cases. Each twelve
hours, 500 milligrams of vitamin C parenterally is ad-
ministered in all cases of upper digestive tract bleeding.
This has been based on the favorable findings by Rivers
and Carlson 5 of the Mayo Clinic, who have used this
agent since 1937 in peptic ulcer regimen. The work on
enteric healing since the original work of these two men
has definitely and conclusively placed ascorbic acid in the
"must” column of treatment sequence. The literature
is copious with unanimous endorsement of this vitamin
in such connection.

Attention should be paid to blood pressure observa-
tion and to the pulse rate taken at hourly intervals and
plotted graphically. By this expedient we are appraised
of new bleeding, and recurrent hemorrhage or persistent
oozing of a lesion is sharply defined. This information,
coupled with observing the efferent debris from the in-
dwelling gastric tube, has frequently indicated the im-
perative need for immediate transfusion. With all def-
erence to plasma and its life saving proclivities, the pa-
tient should be fortified by obtaining at the earliest mo-
ment a quantity of matched citrated blood, placed in
refrigeration, and available for immediate use. Fre-
quently, in repeated copious bleeding, the hematocrit is
not immediately lowered. Procrastination in the matter
of venoclysis should not be indulged when a consistent
fall in blood pressure with increased pulse rate, and the
presence of new blood from the Levin tube exist.

The dietary method of Muehelengracht G in feeding
these bleeders full meals from the day of their accident
through the clinical course of the situation is rather
dogmatic. I have preferred the method of Soper in
what might be termed gastric lavage using the indwell-
ing, intranasal stomach catheter whereby irritating gastric
debris is readily removed and replaced by aluminum
hydroxide drop, with frequent feedings of gelatin and
albumin water for at least four days after the initial
episode. Most certainly Muehelengracht’s claim to more

July, 1946

211

rapid rehabilitation and a more comfortable patient
through his dietary method may be countered by the
more conservative therapy of clysis in the administration
of calories and the correction of chloride deficiency. The
value of early feeding lies in supplying the tissues with
exogenous protein. The mechanical effect of motor and
digestive activity with full feedings may be sufficient to
inaugurate further bleeding The Muehelengracht plan
of feeding must be associated with recurrence of bleed-
ing more than is the case with the more conservative
dietary procedures.

An ideal plan would be the incorporation of all the
advantages of a full dietary intake of protein without
any of its disadvantages. Theoretically at least, the use
of food which is already digested such as "Amigen”*
fulfills this requisite. It readily appears that in this pro-
tein hydrolysate are present the necessary agents for cor-
recting hypoproteinemia. Sufficient calories must be sup-
plied via the optional route along with the protein digest,
or the amino acids will be utilized for caloric requirement
rather than for the correction of the prevailing protein
deficiency. A brilliant report of seventeen cases of mass-
ive bleeding in the upper digestive canal was reported
less than a year ago by Levy,7 showing the efficacy of
this treatment. I have used it recently in two cases of
massive bleeding with most encouraging results.

Recently, concentrated albumin,8 salt poor, of the pro-
tein fraction of human plasma has been made available
commercially. This concentrate was used extensively by
the navy during the recent war in combat casualties,
especially extensive burns and sudden large hemorrhage.
The efficacy of this preparation given intravenously
1.0 cc. per pound of body weight each day is reported
to be remarkable in the immediate correction of hypo-
proteinemia. The navy reports its antishock proclivities
as being five times more rapid than is the action of
standard plasma.

Since the publications of Harkins on alimentary azo-
temia,9 I have adopted the routine of early evacuation
of the bowels. This may safely be accomplished by the
administration of a mild purgative through the indwell-
ing gastric catheter, or in experienced hands, by the
colon tube and syphoning enemata.

Clinicians have all recognized certain manifestations
of toxemia resulting from occult blood in appreciable
amount within the alimentary tract. It has been assumed
that this was from the absorption of the plasma pro-
teins. However, Harkins 10 in his brilliant research series
has conclusively demonstrated both in animal and in
man, that the primary element in producing the eleva-
tion of blood urea nitrogen is the contained hemoglobin
of the erythrocyte fraction of the blood, while the plas-
ma fraction plays a distinctly secondary role. The clin-
ical importance of this work is the fact that it is a defi-
nite contribution in laboratory study to substantiate the
continuation, or cessation of bleeding. This lies in taking
frequent blood urea nitrogen values. It is to Dr. Har-
kins that we owe the term, "alimentary azotemia.”

Observations in cases of massive bleeding have shown

*Amigen (Mead Johnson & Co.), a hydrolysate, dextrimal-
tose, plus acid buffer.

the presence, within a comparatively short time, of a
certain symptom complex that has all the attributes of
uremia. Too often, in the absence of significant urine
findings, the actual existence of a high blood urea nitro-
gen has been overlooked. Many bleeders have shown
uremic symptomatology in greater or lesser degree. They
have developed an actual parenchymatous nephritis as
an obvious complication of the accident in the upper
alimentary tract. I shall report one such case recently
under my care who made his departure via the uremic
route.

The situation of uremia in alimentary azotemia is
somewhat analagous to the uremia that we meet in
severe burns. Perhaps some day soon the physiological
chemists will completely unravel these clinico-pathologi-
cal complexities to the end that we will be fortified with
rational therapy against all similar exigencies.

The intention in this paper has been to emphasize the
immediate care of these cases. Experience directs a
guarded prognosis, particularly in the cases of the late
middle life and old age. This is justified on several
factors; lesser physical resistance, chronicity of the lesion,
and a bleeding hardened vessel in a sclerotic environ-
ment. In all cases of hematemesis and profound melena,
the outcome is doubtful.

The immediate diagnosis of the lesion responsible for
these accidents is distinctly secondary in clinical routine.
Never, until the patient recovers from his original shock
and sequellae, should diagnostic curiosity jeopardize re-
covery. Many of us through our early years were with-
out trained roentgenologists to visualize alimentary
lesions; blood chemistry was in swaddling clothes; and
competent cytologists were too few and remote to be
of value in the exigency. The pendulum of conservatism,
in matters diagnostic in these bleeders, should swing to
the present concept of handling acute skull fracture;
wherein the patient is the element of major importance,
rather than the inherent curiosity of the clinician.

The advent of the gastroscope, the esophagoscope,
and the gastric camera, have all added to diagnostic
armamentarium. A recent series of cases of esophageal
varices treated successfully via the esophagoscope and
sclerosing solution by Patterson and Rouse 11 commands
deepest appreciation. In my practice, this type of diag-
nostic and treatment procedure is not available to my
colleagues or me. We are therefore dependent on the
clinical manifestations, and the correlated findings of
the roentgenologist and laboratorian.

Tribute should be paid to Dr. Frederick Templeton,
of the Cleveland Clinic 12 for his recent volume, "X-Ray
Examination of the Stomach.” As a man outside the
field of radiology, I believe that this described work in
obtaining diagnostic visualization from the visceral rugae,
is an epoch-making contribution in diagnostic gastro-
enterology.

The vast majority of bleeding in the upper digestive
segment is distinctly a medical problem. There may be
surgical indications, with actual operative work accom-
plished, but in the ultimate the case reverts into the lap
of the internist. Recipients of the once popular gastro-
enterostomy to the present radical gastric resection or

212

The Journal Lancet

even total gastrectomy, are people in the present and the
ultimate who require rigid supervision and treatment by
dietary and medical regimen "ad infinitum.” They are
not pleasant responsibilities for those of us in the field
of internal medicine.

Illustrative Cases

Case 1. B. E. W., an office executive, age 48, combat
veteran World War I. Past illnesses, operations, and
habits inconsequential. Thirty minutes after he had
eaten a huge dinner of boiled chicken and dumplings,
topped by two large pieces of apple pie, he was found
in a state of collapse, lying face down in a large pool
of blood on the bathroom floor. He seemed to be quite
dead, and I inquired if he might have attempted self-
destruction. The pupils were widely dilated, there was
no perceptible radial pulse, there was extreme pallor and
a cold clammy sweat. He was hospitalized and imme-
diately given two flasks of plasma, later followed by
500 cc. of citrated blood. His response to this treatment,
together with those methods ordinarily invoked in the
treatment of shock was strikingly satisfactory within
two hours after collapse. He received an additional
500 cc. of citrated whole blood. A few hours later the
hematocrit had approached normalcy. Four days later
he was regarded as being safe for X-ray study. The
laboratory rendered a normal chemo-microscopic report
on study of the aspirated Ewald meal. The radiologist
rendered a negative report after his study. This man
remained in the hospital a total of three weeks under
carefully controlled diet and bed rest. He resumed his
normal employment a month following the chicken din-
ner episode. He has reported at least four times each
year for the past four years for study. He has never
enumerated a single subjective symptom, nor shown a
positive physical finding of a lesion of the upper digestive
tract. He is at the moment a fine and healthy physical
specimen.

Case 2. R. C., a welder in the oil industry, age 51,
likewise a World War I veteran. He had an acute
appendix removed at 21. Had influenza-pneumonia
while in service in 1918. Heavy cigarette smoker all his
life and drank whiskey moderately. Three years ago
was operating a "jack-hammer” some 120 miles distant
from Casper at a remote oil field. Ate a heavy mid-day
meal of hash, boiled cabbage, corn bread and a double
helping of preserved peaches for dessert. He returned
to work, operated the jack-hammer for about thirty min-
utes and was compelled to quit because of dizziness.
Fellow workmen noticed that he was very pale and stag-
gered when he attempted to walk. He was taken to the
camp physician, who gave him a pint of warm soda
solution to invoke vomiting. This failed and the phy-
sician advised that he be taken to his home in Casper.
Enroute to Casper, he fainted in the car and had a
large hematemesis. He was taken directly to the hospital
and admitted on my service. The man was apparently
acutely ill, bordering on collapse. The epigastric region
was distended markedly and there was a flat percussion
note in the region. Blood study revealed a marked low-
ering of hemoglobin and erythrocites and a hematocrit
of 32 per cent. During the physical examination an

involuntary defecation of extreme melena occurred.
Blood pressure 92/ 68, pulse 102. We administered
a 500 cc. flask of plasma and ordered immediate cross
matching for whole blood transfusion. This was ac-
complished within the subsequent two hours, but not
until a very copious hematemesis of bright red gastric
content had occurred. Coagulants were given parenter-
ally and by mouth. Four hours later a second large
emesis of bright red gastric content occurred and the
status of shock was greatly increased. Blood pressure
88/64, pulse 128, hematocrit 28 per cent. Fortunately,
we had refrigerated 500 cc. of blood in anticipation of
such an event. This was given immediately and the usual
treatment of shock continued. Ten hours later the
marked pallor subsided. The general aspect was marked-
ly improved. The hematocrit had approached normalcy
(40 per cent). This man was required to remain in the
hospital with bed rest the subsequent ten days, which
were uneventful. Upon his insistence he returned to his
home, where he rested an additional ten days. He re-
sumed his usual employment twenty-four days after the
onset of the acute affair. I see this man sporadically for
a check-up. He is free of symptoms and physical find-
ings. Subsequent study has included two routine gastro-
intestinal X-ray studies, both of which have been re-
ported negative by the laboratory and the radiologist.

Case 3. J. H., age 36, a steel construction foreman.
For the past three years has had prolonged periods of
indigestion in spring and fall "relieved by baking soda.”
Arising at night with pain, has found that a lunch will
immediately relieve pain in pit of stomach. Has seen
black stools at times during periods of distress. Has
never consulted a physician as he attributed symptoms
to poor food obtainable when working away from home.
Keeps bottle of milk and package of crackers in his
room for night lunches. He arose one morning and
while shaving thinks he fainted. When he resumed con-
sciousness he was on floor of room and had vomited
large amount of dark coffee-ground material. When
he failed to report on job, one of his crew came to
hotel and found him. A physician was called and pa-
tient was advised to return home by ambulance and to
be immediately hospitalized. The 130-mile trip by am-
bulance was accomplished uneventfully, attended by a
graduate nurse. Patient was admitted on my service.
The facies typically that of a patient suffering from
recent severe hemorrhage. There was definite air hun-
ger, the conjur.ctivae were pearly white, blood pressure
88/76, pulse 126. The patient was apprehensive and
persisted in wishing to sit up. Blood study was imme-
diately ordered and while the technician was withdraw-
ing blood, the patient fainted. The syncope persisted
but a few minutes, and was immediately followed by a
large hematemesis and an involuntary defecation of
tarry feces. Morphine was administered perenterally,
hematocrit 28 per cent. A flask of plasma was given
within the half hour subsequent and patient placed in
oxygen tent. Six hours later the patient presented a
much more favorable picture. All evidence of shock had
disappeared, and pulse was of good quality, and of rea-
sonable rate. The patient complained of his usual dis-

July, 1946

213

tress in his upper abdomen. Palpation disclosed a defi-
nite defense reflex and some rigidity three finger breadths
below the mid-portion of the right subcostal region. He
received normal saline and glucose solution alternately
by venoclysis each six hours. Morphine was continued
when indicated for the apprehension and abdominal dis-
comfort. On the fourth hospital day the patient was
studied by the roentgenologist with a small ingestion of
barium. He demonstrated conclusively the presence of
a lesion in the first portion of the duodenum. This was
confirmed a week later by more elaborate X-ray technic.
The laboratory found a marked hyperacidity and con-
siderable erythrocytes in the aspirated Ewald meal. This
patient was hospitalized for the subsequent three weeks
on rigid ulcer diet and acid neutralizing therapy. He
was ultimately discharged on ambulatory ulcer regimen.
He resumed his normal occupation seven weeks after
the acute onset of bleeding. This man soon left the
community, but returned to my office two and one-half
years later to state that he had suffered another similar
attack of hematemesis six months ago and had remained
in the hospital on ulcer diet for six weeks. He was
now on ambulatory diet and had permanently followed
his physician’s admonishment to cease smoking. He is
to all appearances in the best of physical condition and
entirely free of his indigestion. Correspondence with
his physician indicates that the ulcer site in the recent
episode was more distal and of lesser size than the one
found primarily.

Case 4. R. C., age 37, a graduate civil engineer, but
later owner and operator of a small butter-making plant.
Emaciated in appearance, and profoundly myopic. Heavy
cigarette smoker. Presented in the recital of his com-
plaint all the cardinal symptoms of duodenal ulcer. This
was confirmed by the radiologist who demonstrated a
rather large lesion just distal to the pylorus, and with
considerable narrowing of the lumen. The acid curve
was typically high. At this particular time we were ex-
periencing the wave of enthusiasm pertaining to surgery
for this condition. This man was acquiescent to a gastro-
enterostomy and this was accomplished by a highly capa-
ble surgeon. This patient made an enviable recovery,
and soon returned to his butter-making factory. Some
eighteen months later I was called to his home. The
patient had stated that he felt exhausted and desired to
remain in bed for the day. When I arrived at his home
he was lying on a mid-landing of the stairway leading
to the living room. His head was near the top step of
the lower flight of stairs and bloody gastric contents were
actually cascading down the steps to the living room.
He was immediately hospitalized and intravenous physio-
logical solution administered (this antedates the availa-
bility of plasma) . He was in profound shock. Four
hours later a donor of compatible type was secured and
500 cc. of citrated blood were given, promptly followed
by a violent reaction. But strangely the patient survived
both the bleeding and the badly matched blood. Sippy
diet and alkaline therapy were instituted within a few
days, but not until the X-ray study revealed two large
marginal ulcers at the new opening of the stomach. The
patient refused further surgery and agreed to follow a

dietary and acid neutralizing regimen. He refused to
cease using tobacco, and was known to flagrantly violate
his diet and neglect his medication. He had two sub-
sequent massive hemorrhages in two years. He then
developed, plus all his alimentary troubles, a pulmonary
lesion that on study by X-ray and sputum was found
to be pulmonary tuberculosis, from which he died at a
veterans’ facility two years later.

Case 5. A. A., age 40, divorcee One child, 15. Two
induced abortions since. Vaginal hysterectomy five years
ago. Habits good except smokes two packs cigarettes
pier day. Family history negative. Two years ago after
a brief period of indigestion, vomited large quantity of
clotted blood. Was hospitalized by her physician for one
week on strict diet. Had no X-ray study. Followed am-
bulatory ulcer diet prescribed for her but was distressed
in epigastrium almost constantly for the subsequent
seven months. Distress gradually subsided, gained
weight, coior improved, and was able to eat normal diet
and eliminate medication. Two years following the
hematemesis, the patient presented herself for study,
stating she had sustained a blow in the epigastrium in-
curred in an auto accident ten days previously. The
patient was somewhat emaciated and her color was only
fair. Laboratory study indicated a hemoglobin of 78
per cent, RBC 2,260,000, and a normal leukocyte count
and differential, hematocrit 34 per cent. An Ewald meal
disclosed a total acidity of twenty degrees and no free
HC1. Many erythrocytes were noted on microscopic
study of the gastric contents. This patient refused X-ray
study. There was a mild defense reflex in the upper
right portion of the epigastric region and a suggestion
of a nodular mass underlying. Exploration was urgently
recommended but patient refused. Five months later we
received a letter from the chief of a surgical section at
a large mid-west clinic which reported, "exposure through
a primary upper midline incision revealed huge ulcerat-
ing carcinoma involving the posterior wall of the stomach
and forming a circular lesion around the insertion of the
esophagus . There was an indurated area in the right lobe
of the liver, but otherwise there was no definite distant
metastasis. The growth was infiltrating and attached
posteriorly so that any attempt to remove it was out of
the question.” Seventeen days following the receipt of
this communication, the patient had returned, entered
our hospital on my service, and died of exsanguination
via repeated massive hematemesis.

Case 6. J. B., age 48, coin-operated amusement ma-
chine dealer. Gives a negative family history. Married,
has three children, one son, an army pilot killed in Pa-
cific combat. States that he has been constipated and
"off feed” for past two weeks. He has been taking a
bottle of citrate of magnesia each day and has vomited
undigested food occasionally. Has not observed color of
stools. Odor of food occasionally has caused nausea and
impending syncope. Routine physical examination was
made at my office. Temperature, 98, pulse, 114, blood
pressure, 92/74. The patient dressed himself and walked
from a nearby examining room to my private office and
collapsed. A few minutes later he vomited a large amount
of gastric contents containing bright red blood and in-

214

The Journal Lancet

numerable clots. He was immediately hospitalized and
a flask of plasma administered, followed by 1000 cc. of
physiological saline solution. Pressure 90/74, pulse 106.
The hematocrit was quite normal on admittance, (42
per cent) . The urine showed a trace of albumin with an
occasional granular cast present. Blood serology was
negative. This patient recovered from the collapse epi-
sode within a few hours, insisted that he sit up and read
the evening paper and expected to return to his home
the following morning. Against my better judgment he
was permitted to go to his private bath the following
morning, and on returning to his bed had another col-
lapse of lesser degree and without hematemesis. In the
interim we had organized donors who were at the mo-
ment in process of being cross matched. We immedi-
ately gave two flasks of plasma followed shortly by a
severe chill lasting thirty minutes. Four hours later
500 cc. of citrated blood were given. On the occasion of
a visit from his wife the evening of his second hospital
day he had another severe syncope with an involuntary
melanotic stool. The blood picture had dropped from a
normal to Hb. 62 per cent with 2,620,000 R.B.C., hem-
atocrit 28 per cent, blood pressure 86/66, pulse 132.
A consultant from a nearby city was summoned who
sustained my position that this patient was too ill for
X-ray study or exploratory surgery. Periods of mental
befuddlement began to occur. He was placed in an
oxygen tent, and in the subsequent twelve days a total
of nine transfusions and twelve flasks of plasma were
given. The urine progressively showed evidence of acute
nephritis. During the last eighteen hours of life there
was a complete urinary suppression. He died of uremia
on his fifteenth hospital day. An autopsy disclosed, and
I quote the pathologist’s report, "There was slight hard-
ness and hypertrophy in the antral portion of the stom-
ach. The organ contained 1000 cc. of clotted blood and
was dilated. There was an ulcer 2 fi cm. near the
greater curvature in the antral portion of the stomach,
with a definite raised border and a small papillomatous
growth in its center. There was a small (0.5 cm.) ulcer
just lateral to this. The entire antrum in its distal two
thirds appeared infiltrated, more on the greater curva-
ture. There was some narrowing of the pylorus. There
was no evidence of enlarged nodes or metastases to the
liver. The kidneys and remaining organs were pale but
of normal size and contour. Pathological Findings:
Multiple ulcers of greater curvature, grossly appearing
malignant. Histological Findings: There is marked

ulceration of chronic infiltration and acute infiltration
at base of large ulcer. The edge of the ulcer shows
abnormal proliferation of polygonal cells with small
nuclear derangement — definitely abnormal. There is
abnormality of the remaining small portions of the
gastric mucosa surrounding the edge of the ulcer. Diag-
nosis: Adenocarcinoma.”

This patient was fed albumin and gelatin water alter-
nately via Levin tube for forty-eight hours. Parenteral
hemostatic sera were administered at twelve-hour inter-
vals. During the last ten days of life the blood urea
nitrogen values determined by six different observations
progressively rose from the first observation of 32 mg.
to 53.5 mg. a few hours prior to the exodus.

Summary

1. Massive bleeding in the upper digestive tract is distinctly
an emergency invoicing the highest ability and skill of the at-
tending clinician.

2. Immediate clysis of plasma, or better, albumin, salt poor
fraction, whole blood, and indicated physiological solutions are
predominantly imperative throughout critical period.

3. Meddlesome diagnostic and surgical procedure are contra-
indicated until rehabilitation from shock, and the re-establish-
ment of near normal blood status in its entity.

4. Hourly blood pressure and pulse rate observations, fre-
quent hematocrit study, and appraisal of efferent debris from
indwelling gastric catheter, provide significant indications for
transfusion.

5. Feeding of albumin and gelatin waters, protein hydrolysate,
aluminum hydroxide, together with the administration of top-
ical hemostatic are readily accomplished through the Levin tube.

6. The incidence of uremia attributable to alimentary azote-
mia directs frequent blood urea nitrogen estimations for diag-
nostic, treatment, and prognostic values.

7. Massive hemorrhage in the upper segment of the alimen-
tary tract irregardless of intervening treatment, surgical or med-
ical, becomes in the vast majority an ultimate distinct problem
for the internist.

Bibliography

1. Soper, H. W.: Clinical Gastroenterology. St. Louis, Mo.:
C. V. Mosby Co., 1939.

2. Meyer, K. A., and Steigmann, F.: Gastric Hemorrhage:
Implications as to Treatment. Surg. Clin. North America,
24: 29 (Feb.), 1944.

3. Soper, H. W.: Treatment of Hematemesis. J.A.M.A.,

97: 771 (Sept. 12), 1931.

4. Research Lab. Parke Davis & Co. Topical Thrombo-
plastin. Detroit, Mich.

5. Carlson, L. A., and Rivers, A. B.: Clinical Consideration
of Defense Factors of Tissue in the Etiology of Peptic Ulcer.
Rev. of Gastroenterology, 4: 96 (June), 1937.

6. Tice, F.: Gastric and Duodenal Hemorrhage. Practice

of Medicine, vii: 482a.

7. Levy, J. S.: Effect of Oral Administration of Amino

Acids on Hypoproteinemia Resulting from Bleeding Peptic
Ulcer. Gastroenterology, 4:375 (May), 1945.

8. Volkert, M., and Astrup, T.: Effect of Dialyzed Serum
Proteins and Serum Dialysates on Shock. Acta Medica Scan-
dinavica, 115: 537 (Dec. 9), 1943. J.A.M.A. 128:470
(June 9), 1945.

9. Cohn, E. J.: Blood Proteins and Their Therapeutic
Value (as Blood Substitutes). Science, 101: 51 (Jan. 19), 1945.

10. Janeway, C. A.: Clinical Use of Products of Human
Plasma Fractionation: Albumin Shock and Hypoproteinemia;
Gamma Globulin in Measles. J.A.M.A., 126:674 (Nov. 11),
1944.

11. Janeway, C. A.: Concentrated Human Serum Albumin;
Albumin in Treatment of Shock; Safety of Albumin; Albu-
min in Treatment of Hypoproteinemia. J. Clin. Investig.,
23:465 (July), 1944.

12. Warren, J. V., Stead, E. A., Jr., Merrill, A. J., and
Brannon, E. S.: Treatment of Shock with Concentrated Hu-
man Serum Albumin: Preliminary Report. J. Clin. Investig.,
23:506 (July), 1944.

13. Woodruff, L. M., and Gibson, S. T.: Use of Human
Albumin in Military Medicine; Clinical Evaluation of Human
Albumin. U. S. Nav. Med. Bull., 40:791 (Oct.), 1942.

14. Heyl, J. T., and Janeway, C. A.: Use of Human Al-
bumin in Military Medicine; Theoretic and Experimental Basis
for its Use. U. S. Nav. Med. Bull., 40: 785 (Oct.), 1942.

15. Newhouser, L. R., and Lozner, E. L.: Human Serum
Albumin (Concentrated) ; Clinical Indications and Dosage.
U. S. Nav. Med. Bull., 40: 277 (April), 1942.

16. Harkins, H. N., et al: Experimental Studies on Ali-

mentary Azotemia. Surgery, 10:991 (Dec.), 1941.

17. Harkins, H. N., and Chunn, C. F.: Experimental

Studies on Alimentary Azotemia. Surgery, 9:695 (May),
1941.

18. Patterson, C. O., and Rouse, M. O.: Esophageal Var-
ices. J.A.M.A., 130:384 (Feb. 16), 1946.

19. Templeton, F.: X-Ray Examination of the Stomach.

Univ. of Chicago Press, 1944.

July, 1946

215

The Treatment of Prostatism

Oliver Elton Sarff, M.D.

Minneapolis, Minnesota

It is not the purpose of this article to discuss in detail
the pros and cons of the various surgical approaches
for the relief of bladder-neck obstruction, nor to attempt
to mediate the many new concepts of therapy for car-
! cinoma of the prostate. Rather, I shall endeavor merely
to outline the diagnosis and general treatment of pro-
[ static hyperplasia on the basis of my experience in the
: urological service of the State University of Iowa.

In the past several decades there has been an increase
in prostatism, both benign and malignant. Duff,1 work-
ing with the Metropolitan Life Insurance Company,
I found that from 1917 to 1928 life expectancy had risen
from 46 fi to 63 14 years. A man of 60 is more likely
to have a diseased prostate than a man of 50, and the
increase is more marked in each decade after 60 years
of age. Thus we may expect a greater incidence of
prostatism as the life span lengthens.

In 1933, Dr. N. G. Alcock 2 in Iowa reported on a
series of 400 suprapubic prostatectomies. The average
age of the patients was 66.3 years. In a recent survey
at the same clinic it was found that the average age was
74.4 years. This rise in the average age of the patients
is due to two factors, namely, the increase in life ex-
pectancy and the fact that the older and poor risk pa-
tient can now undergo surgery with comparative safety.
Formerly, if he survived, he would have been doomed
to a catheter life or a permanent cystotomy. These im-
provements have been made possible by advances in
chemotherapy and in surgical techniques.

A careful history must be obtained and recorded if
the pathology is to be understood. The symptomatology
varies greatly with the type of lesion and the duration
of the disease. In general there is a tendency toward a
short history in carcinoma, while the benign hyperplasia
will usually show a slow progression over a period of
years, with frequent remissions. The cardinal symptoms
of bladder-neck obstruction are frequency, nocturia,
burning and smarting, dysuria, diminution in the size
and force of the urinary stream, and varying degrees
of urinary retention.

Cases of long standing at times reveal evidence of re-
tention of blood metabolites. In benign hyperplasia
hematuria is not infrequent, but, strangely enough, it
is seldom a manifestation of carcinoma of the prostate.
Carcinoma should be suspected if there is loss of weight,
anorexia, weakness, anemia, low backache, and a sciatic
type and distribution of pain, particularly if the symp-
toms are of short duration.

A careful search should always be made for evidence
of metastasis, as it is too often present before other
symptoms manifest themselves. Bumpus 3 reported a
series in which 25 per cent had metastasis when first
seen at his clinic.

Inquiry concerning the patient’s dietary habits will
give useful information regarding his nutritional status.

An early uremia can be suspected when the history re-
veals poor appetite and nausea. Retention of blood me-
tabolites is indicated if the patient is apathetic and has
a dry skin and tongue. Profound uremia will be self-
evident. A history of shortness of breath, asthma, effort
syndrome, chest pain, and cerebral accidents is of great
value to the physician in evaluating the condition of the
patient and the eventual prognosis. A history of cerebral
disease should put one on guard for a neurogenic
bladder.

The patient should be given a complete physical ex-
amination, with special emphasis on the cardiovascular-
renal systems. A careful rectal examination is of vital
importance in determining the type of pathology. Un-
fortunately, it is not always possible to discern the early
carcinoma per rectum. Kahler 4 studied a series of 490
prostate glands that had been diagnosed clinically as
benign, only to find at post mortem that 54 of them
showed microscopic proof of malignancy. These tumors
were small, limited to one lobe, usually the posterior, and
sufficiently removed from the capsule to make recognition
by a rectal examination possible.

Poor rectal tone suggests cerebral disease and the pos-
sibility of a neurogenic bladder. X-ray studies, consisting
of air cystograms and cysto-urethrograms, are of great
value in diagnosis, and also make preoperative cystoscopy
unnecessary. Experience in interpretation enables the
physician to establish quite accurately the size of the
gland and the type of bladder-neck deformity. At this
time also the amount of residual urine may be deter-
mined and the urine may be studied for any evidence
of infection or renal damage. Evidence of bladder tu-
mor, diverticuli, and ureteral reflux can also be deter-
mined. If there is X-ray evidence of bladder tumor,
intravenous pyelograms should be made to rule out renal
involvement. A complete blood study should be done
routinely, along with cultures of the urine.

If the diagnosis of benign hyperplasia has been made,
one should next decide whether or not surgery should
be undertaken. If the patient carries no residual urine
and the symptoms are minor, consisting chiefly of fre-
quency and nocturia, a conservative regime should be
instituted.

Such a regime includes hot sitz baths, forced fluids,
clearing up existing infection, and such other supportive
treatment as may be indicated. Strictures will have been
noted in the previous examination, and should be given
adequate treatment. If the patient shows improvement
he should be sent home with proper instructions and kept
under observation. Many of these patients can be car-
ried easily and comfortably for years under such a
regime.

If carcinoma is found and the obstructive symptoms
are borderline, a course of stilbestrol is instituted. Ex-
perience shows that many patients respond well and

216

The Journal Lancet

rapidly to such treatment: pain disappears, the patient
voids without difficulty, and appetite and weight are re-
gained. The gland becomes so softened and reduced in
size that many, returning after several months for re-
examination, will defy a diagnosis of carcinoma by rectal
examination.

If the patient fails to respond, or if the obstruction
is complete, surgery is indicated. The patient should be
hospitalized and carefully prepared. Anemias and any
evidence of avitaminosis and nutritional imbalance should
be corrected. If the blood chemistry is within normal
limits and the urine clear, no presurgical bladder drain-
age is necessary. Most patients seen in private clinics will
fall into this group. Ward cases, owing to neglect and
late diagnosis, will more often need indwelling catheters
to eradicate infection and combat uremia. Occasionally
gross hematuria with clot formation, causing complete
retention, will necessitate preoperative drainage. We
have found 1-10,000 zephiran solution to be an excel-
lent medium for intermittent irrigations. Another in-
stance in which indwelling catheter and drainage may be
necessary is for those patients who develop fever and
chills due to bacteremia following X-ray examinations.

In our experience suprapubic cystostomy was seldom
necessary, and then only in the very severe uremic pa-
tient who failed to respond, or in the senile patient whose
co-operation was negligible. If the patient is uremic,
Hartmann solution is of value, and the blood chemistry
and COo combining power should be checked frequently.

In many instances an electrocardiogram will be helpful
in evaluating cardiovascular disease, but only in conjunc-
tion with the clinical findings, which, in my opinion,
take precedence in value.

The clinician can glean much information from ob-
serving the activity of the patient in the wards. Ability
to walk about without effort or discomfort is significant.
The physician should attempt to gain the patient’s con-
fidence and to allay his apprehension. The patient should
be given time to orient himself and opportunity to ob-
serve other patients in various stages of treatment. The
benefit of such measures cannot be overemphasized, for
it is my firm conviction that many coronary accidents
have been directly precipitated by apprehension and emo-
tional stress.

One must be very careful in the choice of sedatives.
These patients do not tolerate well the barbiturates,
which often cause mental confusion. Morphine must be
used with extreme caution, but it still remains the drug
of choice for pain. Paraldehyde in one-dram doses is
useful in combatting restlessness. Preoperative medica-
tion was rarely found necessary in our experience, but,
if it must be given, scopolamine, with a quick-acting
barbiturate such as seconal, gives excellent results. Fluid
balance must be assured before surgery.

We prefer a low spinal anesthesia, and give 75-85 mg.
of novocain dissolved in 1 14 cc. of spinal fluid. It should
at all times be given slowly. Ephedrine should be given
in the amounts indicated and dictated by the blood pres-
sure reading. The blood pressure should be determined
frequently throughout the operation. Adequate therapy
should be given for sudden drops of pressure, for these

elderly patients do not tolerate a profound drop in pres-
sure for any length of time without suffering severe renal
and cerebral damage, often permanent.

The choice of surgery is dictated by the experience
and training of the surgeon available. If a carcinoma
of the prostate is found early and is confined within the
limits of the capsule, radical surgery by a competent man
should be considered. Colston and Lewis reported that
in 1041 consecutive cases of carcinoma, 4 per cent were
considered candidates for radical surgery. For the great
majority, other methods of treatment must be devised.
Treatment is at best merely palliative, but the patient
is entitled to any degree of comfort that can be obtained
for him.

If surgery is required the method of choice is trans-
urethral resection. The only contraindications are ina-
bility to pass the resectoscope or inability to reach a high
intravesical gland. This last condition is occasionally
found in the very obese patient.

We feel that with enough training and experience,
any gland, regardless of size or type, can be successfully
removed. The older the patient and the graver the prog-
nosis, the more important it becomes to attack a pros-
tate by transurethral resection.

We do not hesitate to elect preoperatively to do a
transurethral resection in two stages, for it is our experi-
ence that these elderly, poor risk patients suffer less mor-
bidity and mortality by this method. By doing the resec-
tion in two stages, we can use smaller and therefore less
toxic doses of novocain intraspinally, thus allowing for
less drastic falls in blood pressure, with resultant shock.
We have also found that much more tissue can be re-
moved rapidly during the second stage, owing to the
fact that the tissue is comparatively avascular.

At the time of resection, bladder tumors can be re-
moved by fulguration, stones can be removed by lith-
olapaxy, and the neck of a diverticulum can be resected
to afford better drainage.

In support of our preference for transurethral resec-
tion, we may cite Latchen and Emmet,'1 who, reporting
on a study of material at the Mayo Clinic, stated that
from 1934 to 1942 transurethral resections were done on
345 men of 80 or over, with a mortality rate of 2.6
per cent.

An important advantage of the transurethral method
is that it allows the patient to become ambulatory in
twenty-four to forty-eight hours. Owing to this advan-
tage, the number of cardiovascular and pulmonary acci-
dents that so frequently befall the aged patient forced
to remain in bed for long periods has been reduced.

Postoperative Treatment

In the immediate postoperative period, carbon dioxide
and oxygen are useful in preventing pulmonary and car-
diovascular complications. Adequate fluid balance and
diet are imperative. Hemorrhage and shock should be
treated with whole blood and plasma as necessary. Con-
trary to the experience of others, we have found the
administration of penicillin to be a valuable addition to
the sulfonamides in combatting infection. The blood
pressure should be taken frequently until it becomes
stabilized.

July, 1946

217

If the patient is afebrib, the catheter is removed in
forty-eight hours. The patient should be given ample
i opportunity to void. If he is unable to do so, or if the
residual urine amounts to 100 cc. or more, the catheter
should be replaced for an additional twenty-four to
forty-eight hours, and the procedure then repeated.
Allowance must be made for the large, atonic bladder
; with a history of long-standing retention. Such a pa-
! tient will carry residual urine until the tone of the blad-
der muscle is restored to normal.

, In our experience the average length of hospitaliza-
tion following transurethral resection, including all com-
i plications, is about eleven days, with six days as the usual
period.

Following the patient’s discharge, he should report to
j his local physician or back to the surgeon in the event
j of hematuria, fever and chills, or any other untoward
I symptom. He should be impressed with the necessity
of adequate fluid intake and a well-balanced diet, sup-
j plemented, if necessary, with vitamins.

During the healing period of four to six weeks the
patient should take frequent sitz baths. If the diagnosis
: was carcinoma the patient should be given complete
i instructions in the use of stilbestrol. We have found it
j satisfactory to give 15 mg. of stilbestrol daily, in divided
doses, until the breast becomes tender and enlarged. The
i dose is then cut to an amount that will maintain a
| tender breast without swelling.

The patient should be rechecked within several

months. At this time, the urethra should be calibrated
for stricture or bladder-neck contraction. Except in cases
of malignancy very few will need further treatment.

Summary

Recent advances in surgery, chemotherapy, and other
supportive measures have enhanced the chance of sur-
vival of the elderly, poor risk patient with prostatic
hyperplasia. In our opinion transurethral resection has
given the urologist an instrument that minimizes the risk,
affords a better prognosis, and makes the selection of
cases unnecessary. We may hope that, along with the
increasing incidence or prostatic hyperplasia, both be-
nign and malignant, our knowledge of the branches of
medicine necessary to its successful treatment may be
advanced still further.

Bibliography

1. Duff, J.: Cancer Mortality, Bladder, Kidney and Pros-

tate. J. Urology, 32: 346-353, 1934.

2. Alcock, N. G.: Prostatic Resection and Surgical Prostat-
ectomy; Comparison of Immediate Results in Two Equal Con-
secutive Series of Cases. J.A.M.A., 101: 1355—1358 (Oct. 28),
1933.

3. Bumpus, H. C.: Cancer of Prostate; Difficulties in Eval-
uation of Treatment. Tr. A.M.A. Genital Urinary Surgeons,
34: 191-194, 1941.

4. Kahler, J. E.: Year-Book of Urology. Pages 302-303,
1942.

5. Colston, J. A., and Lewis, L. J.: Carcinoma of the Pros-
tate, a Clinical and Pathological Study. South. M. J., 25: 696-
700, 1932.

6. Latchen, Charles W., Emmet, John L.: Transurethral

Resection for Men 80 or More Years of Age. J. Urology,
53: 482 (March), 1945.

ARMY PROGRAM PREVENTS IMPORTING OF DISEASE

There is little or no risk of introducing foreign disease into the United States through
returning military personnel from abroad, according to an announcement by the Office of
the Surgeon General, which pointed out that the most careful estimates anticipate only mod-
erate danger in a few cases.

This conclusion was reached after a world-wide survey by the Interdepartmental Quar-
antine Commission, which was jointly established by the Secretaries of War and Navy, and
the Administrator of the Federal Security Administration to study this problem.

With the end of the war and return of the bulk of combat forces, it is now possible to
review actual results on a preliminary basis. Though tentative, highly optimistic conclusions
appear warranted, the announcement stated.

To date, no acute outbreak or secondary spread of an imported disease has been reported.
While more slowly evident diseases may be identified later, it should be remembered that the
traffic of war has gone on for four years, giving ample time for discovery of such diseases.

The 440,000 hospitalizations for malaria reported among Army personnel during the
war fall short of pessimistic predictions for what has proved to be the commonest infectious
disease of troops abroad.

Even with the consideration that a portion of infected persons are liable to recurrence
after their return to the States, conditions in this country are generally unfavorable for the
spread of malaria and the chances of community risk are very small.

The special danger of cholera, smallpox, plague, epidemic typhus, and yellow fever, is
a matter of historical record. Immunizations were employed against all these diseases by the
Armed Forces along with water purification, environmental sanitation, and disinfestation and
insect control. This preventive medicine program was exercised even under combat conditions
and its effectiveness was shown by Army records. The high general level of sanitation, insect
control, and alert medical care available here forms the final link in the protection of this
country from imported diseases. — War Medicine, May 1946.

218

The Journal Lancet

Hypochromic Anemia: Treatment with
Molybdenum-Iron Complex

James C. Healy, M.D.*

Boston, Massachusetts

Although iron is regarded as a specific in the treat-
L ment of hypochromic anemia, it is well known that
relatively small amounts of the elements are absorbed,
and still smaller amounts utilized, following oral admin-
istration of therapeutically adequate doses of iron prepa-
rations.

Various means of potentiating the therapeutic action
of iron, by facilitating absorption or utilization of the
metal, have been studied. For example, enhancement of
the action of iron by calcium,1 cobalt,2 preformed pyrol
substances such as chlorophyll 1 and "secondary anemia”
liver extract 1 has been observed. However, the practical
value of such "accessory substances” in the treatment of
hypochromic anemias is at best doubtful, since their po-
tentiation of iron can be demonstrated only in animals
and, as emphasized by Witts,5 only when suboptimal
amounts of iron preparations are used.

In the investigation of the possible catalysis of iron
by "accessory substances,” most attention has been given
to copper. This element has been clearly shown to po-
tentiate the action of iron in experimental animals made
anemic by a diet deficient in both copper and iron.6 Its
importance as an adjuvant to iron in the treatment of
clinical anemias, however, seems to be limited to a mi-
nority of patients, notably young infants, apparently be-
cause of the rarity of copper deficiency among other age-
groups in man.'

Present Study

The purpose of this paper is to report the results of
an endeavor to determine the therapeutic efficacy of a
molybdenum-iron complex in patients with hypochromic
anemia. Preliminary study of this preparation had dem-
onstrated its lack of toxicity in guinea pigs and rabbits
and suggested its usefulness as a valuable hemopoetic
agent in clinical hypochromic anemia.

Molybdenum-iron complex, hereafter designated "M-I
complex,” is said to be prepared by a process in which
molybdenum sesquioxide (Mo^O.-j) and ferrous sulfate
are co-precipitated to produce a homogeneous mass con-
taining a partial physical union of the component salts.
The preparation was administered to patients in the form
of tablets, f each of which supplied approximately 2.5
mg. of elemental molybdenum and 40 mg. of ferrous
iron.

Procedure

The therapeutic value of M-I complex, as compared
with ferrous sulfate, was studied in seventy cases of mod-
erately severe hypochromic anemia among hospitalized
individuals who were largely ward patients. Forty-nine
patients (Group I) were treated with tablets of M-I
complex; the remaining twenty-one patients (Group II)

’Department of Pharmacology, Tufts College Medical School.
fSupplied by White Laboratories, Inc., Newark, N. J.

served as controls and were treated with tablets of ex-
siccated ferrous sulfate.

According to whether anemia was obviously the result
of protracted hemorrhage or was associated with a state
of gross malnutrition and not apparently the result of
hemorrhage, patients of each group were divided into
two sub-groups and designated as having either post-
hemorrhagic hypochromic anemia or nutritional hypo-
chromic anemia.t Those with post-hemorrhagic hypo-
chromic anemia were selected for study after preliminary
control periods without therapy had demonstrated no
improvement in the anemia.

All blood studies were done in duplicate by one ex-
perienced technician to insure greater accuracy. The av-
erage of each duplicate reading was recorded as the true
laboratory finding. Hemoglobin determinations were
made by an acid hematin method in which 100 per cent
hemoglobin is equivalent to 14.5 Gm. per cent. Follow-
ing the diagnosis of hypochromic anemia and the start
of treatment in each case, examination of the blood was
made usually at intervals of three to four days during
the course of study. The rate of hemoglobin regenera-
tion was regarded as the yard-stick of therapeutic efficacy
of the iron medication.

Results

The degree of anemia in both groups of patients at
the beginning of treatment was comparable, the average
initial hemoglobin in Group I being 8.41 Gm. per cent
and that in Group II, 8.18 Gm. per cent. The average
daily intake of elemental iron in Group I was approxi-
mately 230 mg. (as M-I complex) and, in Group II,
approximately 380 mg. (as ferrous sulfate) . Both M-I
complex and ferrous sulfate were administered to pa-
tients in divided daily dosage of four to eight tablets.

The patients in Group I responded to treatment with
M-I complex in a strikingly favorable manner. Normal
hemoglobin levels were attained by all patients in this
group within a period of time ranging from 9 to 3 1 and
averaging 13.7 days. The average daily increase in
hemoglobin for the group was 0.36 Gm. per cent. On
the other hand, the therapeutic response to ferrous sul-
fate in patients of Group II was definitely less favorable.
In a period ranging from 15 to 24 and averaging 20.7
days, during which the results of treatment with ferrous
sulfate were observed, only two patients attained a hemo-
globin level as high as 12 Gm. per cent, a value consid-
ered to be a low normal. Normal hemoglobin values
were not reached in the remaining seventeen patients

JThe term, "nutritional hypochromic anemia,” is used in
deference to the gross malnutrition of these patients in whom,
it is recognized, factors such as undetected previous hemorrhage,
altered gastrointestinal function and chronic infection were pos-
sibly of greater importance than poor diet in the causation of
anemia.

July, 1946

219

Table 1

Individual Response to Treatment with Molybdenum-Iron Complex

Case

No.

Initial Hemoglobin

Days of
Treat-
ment

Therapeutic
Intake of Fe + +
(in Gm.)

Total Hemoglobin
Increase

Average Daily
Hemoglobin Increase

Per Cent
Utilization
of Fe + -f-

Per Cent

Gm. %

Per Cent

Gm. %

Per Cent

Gm. %

POST-HEMORRHAC

3IC HYPOCHR

OMIC ANEMIA

8.70

3 744

3 34

1.43

.207

15 3

6 52

9 672

5.08

1.12

162

9.0

5 51

8 736

7.40

1.82

263

14 4

9 86

8 914

3 19

1.09

158

11 1

7 54

3 744

5.51

2 37

343

25 . 3

7 54

5 616

5.08

1.94

.281

15.5

7 54

6 552

6 37

1.76

255

14 1

7 98

5 928

4.21

1.52

.220

12 2

6 67

6 864

5.08

1 59

.230

12.7

10.

5.51

6.240

5.51

1.90

284

15.2

11.

8 99

3 744

4.06

1.74

252

18.6

12.

8.85

2.808

2 76

1.58

229

16 9

13.

6.67

8.112

5.51

1 46

211

11 7

14.

6 96

4 992

5.51

2 37

.343

19.0

15.

10.01

1 248

3 63

2 08

.301

50.0

16.

9 28

1.404

4.06

3.11

450

49 8

17.

8 41

2.808

4 79

3 66

530

29.3

18.

9.28

2 106

4.21

3 22

466

34 5

19.

10.30

1.404

3 34

3 83

.555

40.9

20.

8 41

3 744

5.51

3.16

.458

25 3

21.

8.70

2 106

4.50

3 33

482

36 7

22.

8 70

2.808

4.64

2 66

.385

27.7

23.

9.57

2 106

3 63

2.79

404

29 6

24.

7 11

4.680

5 66

2.60

. 377

20 8

25.

10.15

2.106

3.05

2.33

.337

24 9

26.

9 14

2.808

4.35

2.50

362

26 7

27.

8 99

3 978

4.50

1.82

263

19 4

28.

8.85

2 106

4.06

3.11

450

33 2

29.

7 25

1.872

5.22

3 00

435

48.0

30.

7.54

3 744

5.37

3 08

446

24.7

31.

9.14

2.340

3 34

2 30

333

24.5

32.

9.14

4.212

4.21

1 61

233

17 2

33.

8.12

3.744

4 50

2 58

374

20 6

34.

7 40

4 680

5 66

2.60

.377

20 8

35.

8.41

4.056

4.50

2.38

.345

19 1

36.

8 85

2 106

3 48

2 66

.385

28.4

37.

8 56

2 340

4.06

2 80

406

32.0

NUTRITIONAL

HYPOCHROM

IC ANEMIA

38.

9 86

2 106

3 77

2.88

.417

30 8

39.

8 41

2.574

4 93

3.09

.448

33 0

40.

8 85

1 872

4.50

2.58

.374

41.3

41.

8.70

1 . 560

4 21

2.90

. 420

46 4

42.

8 85

2 808

4 93

2 83

.410

30 2

43.

8.41

2 340

4.50

3.10

.449

33 1

44.

8 85

2.106

4.50

3 33

.482

36 7

45.

9.57

1 560

4.06

2.80

.406

44 8

46.

8 99

1 872

4.79

2.75

398

44 0

47.

8 85

2 808

4.79

2.75

.398

29 3

48.

7 54

3 042

5 94

3 15

.456

33 6

49.

9 28

2.106

4 35

3 33

482

35 6

Table 2

Individual Response to Treatment with Ferrous Sulphate

Case

No.

Initial 1

lemoglobin

Days of
Treat-
ment

Therapeutic
Intake of Fe + +
(in Gm.)

Total H
Inc

emoglobin

rease

Average Daily
Hemoglobin Increase

Per Cent
Utilization
of Fe -f- -f-

Per Cent

Gm. %

Per Cent

Gm. %

Per Cent

Gm. %

POST-HEMORRHAC

IIC HYPOCHR

OMIC ANEMIA

7 68

11 520

2 61

.75

108

3 91

8.12

9 120

2.46

.89

129

4 66

7.54

9.600

2 90

1.00

145

5.20

7 10

11.040

3 34

1.00

145

5 20

7 68

5.160

1.45

.065

4 84

7 68

10.560

2 90

.90

130

4 73

7.10

5.520

3 48

1.00

. 145

10.80

8.12

8.280

3.05

131

6 34

8 85

7 200

2 32

116

5 55

10.

7.83

9.120

3.05

1 . 10

159

5 75

11.

8 70

5.340

2.90

.95

. 137

9 36

12.

8 41

8 640

2.17

.089

4.34

13.

8 12

11.520

3 48

1.00

. 145

5.20

14.

9 28

4.440

2.17

. 120

8.44

15.

8 56

5.760

2.17

.93

134

6 51

16.

9 14

5 . 760

1.74

.75

108

5.20

17.

9 28

5 400

1.88

124

6.01

18.

8 56

8.280

2.61

.78

.113

5 43

NUTRITIONAL

HYPOCHROM

IC ANEMIA

19.

8 85

4 320

1.45

.095

5.78

20.

7.10

10.080

2.90

.95

137

4.96

21.

8.12

8.640

1.74

.095

3.47

220

The Journal Lancet

Table 3

Average Results of Treatment with Molybdenum-Iron Complex and with Ferrous Sulphate

No.

Cases

Initial Hemoglobin

Days of
Treat-
ment

Therapeutic
Intake of
Iron

(in Gm.)

Total Hemoglobin
Increase

Average Daily
Hemoglobin Increase

Per Cent

Gm. %

Per Cent

Gm. %

Per Cent

Gm. %

GROUP I: Hypochromic Anemia

8.41

13.7

3.528

4 56

2 48

.360

A. Post-Hemorrhagic

8 27

14.6

3.950

4.54

2.35

.340

B. Nutritional

8 85

10.8

2 229

4.61

2.96

.428

GROUP II: Hypochromic Anemia

8 18

20.3

7.871

2.51

.83

.120

A. Post-Hemorrhagic

8.21

20.7

7 903

2 59

.125

B. Nutritional

8.02

7.680

2 03

.76

.109

Treatment: Group I - Molybdenum-Iron Complex
Group II — Ferrous Sulfate

during the period of observation. The average daily in-
crease in hemoglobin in Group II was 0.12 Gm. per
cent, significantly lower than the average daily increase
of 0.36 Gm. per cent in Group I.

Per cent utilization of iron was also notably different
in the two groups of patients. The percentage of orally
administered iron utilized in the formation of hemo-
globin was estimated according to the method reported
by Fullerton,8 in which a 1 per cent rise in hemoglobin
represents an iron utilization of 25 mg. Calculated in
this manner, the daily utilization of iron by patients
treated with M-I complex (Group I) varied from 9.0
to 50.0 per cent, while those treated with ferrous sulfate
(Group II) had a daily utilization of the metal ranging
from 3.5 to 10.8 per cent. Since the average intake of
therapeutic iron by patients in Group II was greater than
in Group I, the percentage of utilization would naturally
be somewhat less in the former but not sufficiently so
to account for the substantial difference in utilization in
the two groups as calculated.

The individual results of treatment with M-I complex
are presented in Table 1 and the results in the control
patients, treated with ferrous sulfate, in Table 2. The
average response to treatment of both groups of patients
is summarized in Table 3.

It is important that an iron preparation, orally admin-
istered to patients with hypochromic anemia, not only
be therapeutically effective but also tolerated wihout un-
due gasrointestinal distress. Among the forty-nine pa-
tients of Group I who were treated with M-I complex,
only one complained of mild distress in the form of ab-
dominal cramps, which disappeared with reduction of
the dose of the preparation. Of the twenty-one patients
treated with ferrous sulfate, however, six complained of
gastrointestinal disturbances from the medication that
necessitated its discontinuance in one but were alleviated
in the remaining five by decreasing the dose.

Comment

The rate at which hemoglobin formation occurs in the
treatment of hypochromic anemia is roughly in direct
proportion to the severity of the anemia. In moderately
severe anemia with hemoglobin values of 7.25 Gm. per
100 cc. (50 per cent) or less, daily increases in hemo-
globin of 0.14 Gm. per 100 cc. (1 per cent) or more
for several weeks are regarded as satisfactory; the rate

of hemoglobin formation then slows progressively as the
hemoglobin approaches normal.0

In the patients of Group II the rate of hemoglobin
regeneration in response to treatment with ferrous sulfate
averaged 0.12 Gm. per cent daily, which can be properly
regarded as a satisfactory therapeutic response. It is
obvious, then, that the average rate of hemoglobin for-
mation in those patients treated with M-I complex (0.36
Gm. per cent daily) is unusually rapid.

An equally unusual feature of the observed therapeutic
response to M-I complex was the almost uniform rate
of hemoglobin formation throughout treatment in each
patient. The progressive slowing of hemoglobin forma-
tion, which one expects to observe as hemoglobin values
approach normal, was conspicuously absent in the re-
sponse to treatment with M-I complex and definite re-
tardation of hemoglobin formation usually occurred only
after normal values had actually been reached.

From our observation it seems clear that M-I complex
is an unusually effective agent for the treatment of hypo-
chromic anemia and is well tolerated in adequate dosage.
No effort has been made in this study to determine the
mode of action of the molybdenum component of this
preparation. However, it is believed that the therapeutic
response to M-I complex observed in our patients, is a
true example of potentiation of the therapeutic action of
iron, which manifestly is brought about either by in-
creased absorption or by more complete utilization of
iron. The exact mechanism by which such potentiation
is accomplished is a problem, investigation of which is
beyond the scope of this report.

Summary

1. Among a total of seventy hospitalized and mostly
ward patients with moderately severe, posthemorrhagic
or nutritional hypochromic anemia, forty-nine patients
(Group I) were treated with a specially prepared com-
plex of molybdenum sesquioxide and ferrous sulfate and
twenty-one (Group II) with ferrous sulfate alone.

2. The degree of anemia in both groups of patients
at the beginning of treatment was comparable, the av-
erage initial hemoglobin in Group I being 8.41 Gm.
per cent and in Group II, 8.18 Gm. per cent.

3. The response to treatment in Group I was un-
usually satisfactory; normal hemoglobin levels were at-
tained by all patients in this group in an average time

July, 1946

221

of 13.7 days and the mean daily increase in hemoglobin
for the group was 0.36 Gm. per cent.

4. Only two patients of Group II attained normal
hemoglobin levels in response to treatment with ferrous
sulfate in a period of time averaging 20.7 days and the
mean daily increase in hemoglobin for this group was
0.12 Gm. per cent.

5. The percentage utilization of iron, calculated as
described, was significantly greater among patients of
Group I than in Group II.

6. The molybdenum-iron complex used in this study
seems to be unusually effective and well tolerated in the
treatment of hypochromic anemia. The therapeutic re-
sponse in patients treated with this preparation is appar-
ently an example of true potentiation of the hemato-
poietic action of iron, although the exact manner in
which such potentiation is accomplished has not been
determined.

References

1. Kato, K., and lob, V.: Influence of Cobalt on Iron

Transportation and Storage: A Chemical and Histological

Study. Am. J. Clin. Path., 10:751, 1940.

2. Orton, J. M., Smith, A. H., and Mendel, L. B.: Rela-
tion of Calcium and of Iron to the Erythrocyte and Hemo-
globin Content of the Blood of Rats Consuming a Mineral
Deficient Diet. J. Nutrition, 12: 373, 1936.

3. Patek, A. J.: Chlorophyll and Regeneration of the Blood.
Arch. Int. Med., 57: 73, 1936.

4. Whipple, G. H., Robscheit-Robbins, F. S., and Walden,
G. B.: Blood Regeneration in Severe Anemia. Am. J. Med.
Sci., 179: 628, 1930.

5. Witts, L. J.: The Therapeutic Action of Iron. Lancet,
1: 1, 1936.

6. Hart, E. B., Steenbock, H., Waddell, J., and Elvehjem,
C. A.: Iron in Nutrition. VII. Copper as a Supplement to
Iron for Hemoglobin Building in the Rat. J. Biol. Chem.,
77: 797, 1928.

7. Hahn, P. F.: Metabolism of Iron. Medicine, 16:249,

1937. — • Wintrobe, M. M.: Clinical Hematology. Lea &

Febiger, Phila., 1942.

8. Fullerton, H. W.: The Treatment of Hypochromic

Anemia with Soluble Ferrous Salts. Edinburgh Med. J.,
41: 99, 1934.

9. Heath, C. W., Strauss, M. B., and Castle, W. B.: Quan-
titative Aspects of Iron Deficiency in Hypochromic Anemia:
Parenteral Administration of Iron. J. Clin. Invest., 11: 1293,
1932. — Goodman, L., and Gilman, A.: The Pharmacologic
Basis of Therapeutics. Macmillan Co., N. Y., 1941.

SURGEONS NOW ADVISE "RISE, WALK” ROUTINE

Of recent years, newspapers have brought to the public’s attention in understandable
language, news of new pharmaceuticals and new technics in treatment. A fair example of
a " medical news story” is the following from the Minneapolis (Minnesota) Tribune of
late June 1946.

Staying in bed for days after a serious operation usually does more harm than good to
the patient, doctors at University hospital* have found.

While European doctors, for many years, have followed the lead of a Chicago gynecolo-
gist in getting their patients out of bed for a few minutes on the day following an operation,
most American doctors have been unconvinced of the soundness of the routine.

Doctors in the surgery department at University hospital decided to test the plan for
themselves.

They had watched army and navy doctors successfully use the "out of bed in a hurry”
treatment on wounded servicemen, and some civilian hospitals, too, had begun to advocate
the routine because of overcrowded conditions and staff shortages.

The experiment at University hospital was conducted with two sets of patients, all of
whom had undergone abdominal operations.

The first group of 50 patients was operated on in 1942; the second group in 1945.

Patients in the first group were allowed to get up a few minutes about the eleventh day
of hospitalization. The average patient in the second group was up briefly on the third day,
but an effort had been made to get him up on the first day.

No patient in either group was urged to walk if he felt too ill to do so, or if complica-
tions had set in following his operation.

When the experiment was completed, the doctors recorded some conclusive results.

Patients allowed to get up a short time following an operation suffered no harmful ef-
fects. Any complications which set in were caused by the extent of the patient’s disease and
surgery.

Improvements of the general strength and morale of the patient was evident, and a de-
crease in postoperative discomforts, such as gas pains, was marked.

The duration of the patient’s hospital stay was reduced by an average of five days.

Some doctors outside University hospital thought early ambulation prevented embolism —
blood-clotting in the veins — and reduced the danger of postoperative pneumonia.

Although the experiment was limited to patients with abdominal operations, university
doctors more recently have approved the routine for almost all surgery patients.

(Hospital at University of Minnesota.)

222

The Journal Lancet

A Report on the Use of Two Thousand Units of
Dried Plasma Under a State-Wide Health
Department Program*

Melvin E. Koons, M.Sc., M.P.H.f
Grand Forks, North Dakota

The purpose of this paper is to give a report on the
use of dried plasma which was distributed through
a state-wide program for use in civilian medical practice
by the North Dakota State Health Department. Statis-
tics are based on the first two thousand reports regard-
ing the use of plasma received in the North Dakota
Blood Plasma Laboratory.

When the free plasma service was first instituted in
North Dakota, there was some doubt as to how much
plasma would be used by the medical profession in its
routine practice. A preliminary survey of the use of
plasma in the state showed that very little was being
used by hospitals in the larger urban centers and prac-
tically none in the smaller rural hospitals. Then, too,
there was no plasma available to individual physicians
located in rural areas where hospitals are not easily
accessible. When time is an important factor, transfu-
sions could be started without removing the patient to
a hospital if plasma were available.

At the beginning of the state program, approximately
fifteen hospitals had limited supplies of commercial dried
plasma and small liquid plasma banks. Prior to the war
the medical profession at large had little opportunity
for personal experiences with the use of plasma. Very
few doctors used plasma for transfusions because its
value had not been adequately proven nor had the re-
sults of its use appeared too extensively in the literature.
Then, too, the use of commercial plasma was restricted
somewhat by its high cost, which for many patients lim-
ited its use. The successful use of plasma by the Armed
Forces during the war period has resulted in a wide-
spread demand that this material be made available to
the civilian population. At about the time when plasma
was being utilized and its value recognized by the med-
ical profession, the North Dakota program was started.

The original investigations with plasma were done on
the basis that plasma could be used as a substitute for
whole blood. However, work in recent years has shown
that plasma is a therapeutic agent in its own right.
There are definite indications for the transfusion of
whole blood, but they are few as compared to the indi-
cations for the transfusion of blood plasma. As will be
noted later, 50 per cent of the plasma used in North
Dakota is for the treatment of shock cases with post-
operative cases in the majority.

Strumia and McGraw 1 summarize the indications for

*This is a follow-up of an article by the same author en-
titled, "Free Piasma Service in North Dakota,” which appeared
in the January 1946 issue of Journal Lancet.

fDirector, Division of Laboratories, North Dakota State
Health Department.

plasma as follows: (1) shock with little or no hemor-

rhage; with severe hemorrhage, plasma for immediate
relief, followed by whole blood if warranted; (2) bums
(whole blood contraindicated because of hemoconcentra-
tion) ; (3) infections — as a means to supply specific and
non-specific immune bodies (supplemented by whole
blood when severe anemia is present) ; (4) hypoprotein-
emias, nutritional, hepatic, nephrotic, and from various
other causes; (5) cerebral edema, such as accompanies
injuries, toxemias, and so on (plasma in concentrated
form) ; (6) certain blood dyscrasias, such as those with
hemolytic tendencies, those with low prothrombin con-
tent, et cetera.

Table 1 shows a complete classification of the reports
received on the use of the first two thousand units of
plasma; these units were used on 1065 patients. One
cannot predict how the next two thousand units will be
used; however, the distribution in regard to the clinical
condition may well follow the pattern set by the first
two thousand units. It is interesting to see that 57.7
per cent of the total number of patients receiving plasma
were treated for some form of shock and 18.5 per cent
were classified as obstetrical patients.

Table 1

Classification of Reports on

the Use of Plasma

Condition
for Which Used

Number

Patients

Per Cent
of

Total

Number

Units

Used

Per Cent
of

Total

Shock

615

57.7

1012

50.6

Burn

3.5

112

5.6

Obstetrical

1 96

18.5

306

15.3

Hemorrhage

3.6

3.5

Hypoproteinemia

7.1

336

16.8

Infection ...

3.7

3.1

Communicable Diseases

0.8

1.1

Miscellaneous

2.3

2.0

Not classified

2.8

2.0

Total

1065

100.0

2000

100.0

Table 2 shows the total number of deaths occurring

in the group of patients who

received plasma. Here

Table 2

Classification of Deaths in Treated Group

Total

Patients Number

Type of Condition

Receiving

Plasma

Deaths

Per Cent
Deatha

Shock (all types)

615

7.3

Burn

19.4

Obstetrical

196

2.5

Hemorrhage (all types)

18.4

Hypoproteinemia

1 18

Infection

20.0

Communicable Diseases

44.4

Miscellaneous

8.0

Unclassified

10.0

Total

1065

8.4

July, 1946

223

again, no inference can be drawn as to the significance
of these figures, as there is no comparable group which
did not receive plasma. We, of course, would like to
believe that the death rate would have been higher if
plasma had not been used and there is no doubt but
that plasma helped to save the lives of a certain number
of these patients, as plasma is frequently given as a life-
saving measure.

Table 3 gives an analysis of the shock cases for which
approximately 50 per cent of the two thousand plasma
units were used.

Blood, or a blood substitute, is essential as a thera-
peutic measure in all conditions characterized by a re-
duced circulating blood volume. It is also true that there
may be many instances where plasma is used as a pre-
liminary first aid measure with later whole blood trans-
fusions being necessary. This is especially so in trau-
matic shock accompanied by hemorrhage.

Elliott,2 in 1936, suggested the use of plasma for treat-
ment of traumatic shock. He believed that the blood
volume restoration was important to maintain osmotic
pressure as a function of the plasma proteins. In the
treatment of shock it is an accepted fact that the blood
volume must be brought back to normal as rapidly as
possible.

Plasma was recommended in 1939 as an ideal substi-
tute for whole blood in shock and hemorrhage from war
wounds by Tatum, et al.3 This recommendation may
well be applied to civilian cases with the same excellent
results. Authorities 4 have stated that "Plasma appears
to be from all standpoints the ideal material for the per-
manent re-establishment of proper circulation in sec-
ondary shock.”

The death rate of 7.3 per cent, as shown in Table 3,
is not high when one considers the type of cases involved.
The death rate in traumatic shock was the highest, which
could be expected, as this group contains all of the acci-
dent cases where death may have been attributable to
a number of things.

In checking over the reports, it was noted that many
of the postoperative deaths were in patients beyond sixty
years of age.

Table 3

Analysis of Shock Cases

Number

Number of

Per

of Units

Cent

Classification

Patients Used Deaths

Deaths

Postoperative shock

327

532

1 8

5.5

Postoperative hemorrhage

with shock ....

Operative shock

Operative shock with homorrhage

Preoperative shock

with hemorrhage

Prophylactic shock:

Postoperative

Preoperative

Operative

Traumatic shock:

With marked hemorrhage

173

10.2

Without marked hemorrhage

120

20.1

Spinal anesthesia shock

Coronary occlusion shock

50 0

Shock with anoxemia

Total ... .

615

1012

7.3

Table 4 shows an analysis of the obstetrical cases
which received plasma. A total of 196 patients was
treated with 306 units of plasma. Over 50 per cent of
these cases was treated for postpartum hemorrhage.

Tisdall,5 in 1941, reported on the use of plasma in
obstetrics. He pointed out that obstetric hemorrhage and
shock require immediate and adequate replacement of
blood volume. This can adequately be taken care of by
the transfusion of plasma, although there may be cases
where later whole blood transfusions are valuable.

The highest death rate in the obstetrical cases occurred
in the ectopic pregnancy patients. Both deaths were rup-
tured cases. Since the 196 cases treated in this group
constituted 18 per cent of the total number, this table
seems to bear out the conclusion that plasma does have
a place in obstetrical cases and should be available for
use in all hospitals.

Table 4

Analysis of Obstetrical Cases

Number

Per

Units

Cent

Classification

Patients

Used

Deaths

Ectopic pregnancy

1 5

13.3

Spontaneous abortion

Incompelte abortion

1 1

Threatened abortion

Miscarriage with hemorrhage

Postpartum hemorrhage

112

176

1.8

Postpartum toxemia

Postpartum infection

Prepartum hemorrhage

Placenta praevia .............

5.0

Abruptio placenta with hemorrhage

Excessive vaginal bleeding

Preeclamptic

Difficult labor

Total

196

306

2.5

In most cases of hemorrhage, plasma finds its useful-
ness as a preliminary and expedient method, generally
followed by whole blood transfusions. Table 5 gives an
analysis of hemorrhage cases in which plasma has been
used.

Table 5

Analysis of Hemorrhage

Cases

Number

Per

Units

Cent

Classification

Patients

Used

Deaths

Intestinal hemorrhage

25.0

Uterine hemorrhage

20.0

Prostatic hemorrhage

100.0

Bladder hemorrhage

Internal hemorrhage

Stomach ulcer (hemorrhage)

Gastric hemorrhage ...

30.7

Duodenal ulcer (hemorrhage)

Endocarditis with hemorrhage

Total

18.4

Ward,6 in England, first proposed the use of human
blood plasma as a substitute for whole blood in hemor-
rhage cases. He observed that death was due to a loss
of fluid rather than to loss of cells and suggested replace-
ment of depleted fluid with citrated plasma. At about
the same time Rous and Wilson ‘ successfully treated
experimentally produced hemorrhage in animals with
plasma injection. In the treatment of hemorrhage, their
theory was that a return to normal level of plasma vol-

224

The Journal Lancet

ume was the most important factor, the cells remaining
in sufficient quantity. Therefore, it is essential that blood
volume be re-established as soon as possible following the
hemorrhage. With plasma available, this emergency
measure may be taken in the home, immediately, before
the patient is removed to the hospital.

In the thirty-eight patients treated there was a death
rate of 18.4 per cent, the greatest number of deaths
occurring in gastric hemorrhage cases. One can readily
see that while the number of cases treated was not high,
there is a variety of hemorrhagic conditions in which
plasma can be used to good advantage.

Table 6 gives an analysis of the hypoproteinemia cases
which were treated with plasma. Seventy-six patients re-
ceived a total of 336 units of plasma, with a death rate
of 11.8 per cent.

Treatment of these cases is an attempt by the physi-
cian to restore the normal protein content of the plasma.
Hypoproteinemic conditions may be brought about when
the protein intake is insufficient or when there is a
chronic loss of protein. Generally a tissue edema results
from this decrease in the protein content of the plasma
and by transfusing plasma the condition can be markedly
improved in a short while.

That plasma is indicated in a variety of those cases
where protein levels are low is also shown in Table 6.
The large number of unclassified cases were not fol-
lowed up. The reports on these merely stated that the
patients were treated for hypoproteinemia. If the cause
for the protein deficiency had been indicated, it is prob-
able that the list showing the types of conditions would
have been more varied.

One case probably should be mentioned, that listed as
an enterostomy. This was performed on a man 56 years
of age who, before he died, received the amazing total
of 77 units of plasma during a period of approximately
two months. This is the only nourishment the patient
received and the physician reported that the patient
showed a definite improvement after the first month and
there was some hope that he would recover.

Table 6

Analysis of Hypoproteinemia Cases

Condition

Number

Patients

Number

Units

Used Deaths

Per

Cent

Death;

Nephrosi s

3 1

Peritonitis

Carcinoma of stomach

Postoperative

16 2

50.0

Infection

1 1

Enterostomy

77 1

100.0

Addison’s disease

Gastric hemorrhage

.. 2

Glomerulitis

Celiac syndrome

Senile

Unclassified

172 6

11.5

Total

336 9

1 1.8

Table 7 is an analysis of the use of plasma in cases
of infection. As shown in the table, forty cases were
treated with 63 units of plasma, with a death rate of
20.0 per cent. Here again, the unclassified cases were not
followed up and no evidence is at hand whereby the
type of infection could be classified. The table does

show, however, that the use of plasma may well be in-
dicated in many types of infections and would be used
more frequently if it were available.

Table 7

Analysis of Infection Cases

Number

Number of

Per

of Units

Cent

Condition

Patients Used Deaths

Deaths

Appendix

Arthritis

Empyema

Pelvic inflammation

Kidney infection

Postoperative infection

Pleurisy with effusion

100.0

Septic myocarditis

50.0

Exfoliated dermatitis

Enteritis

Peritonitis

Mediastinitis

Not classified

27.2

Total

20.0

Table 8 is an analysis of communicable disease cases
for which plasma was used. It is evident that no conclu-
sion can be drawn from this table because of the rela-
tively small number of cases; however, it should be
pointed out that plasma may in the future have a more
definite place in the treatment of infectious diseases.
Convalescent sera has been used with good results in
the treatment of certain of the infectious diseases. Pooled
normal adult plasma is one-fourth as potent as conva-
lescent sera and if used in adequate dosage equally good
results may be obtained. The use of plasma in the treat-
ment of certain of the communicable diseases may war-
rant more study to determine its value.

Table 8

Analysis of Communicable Disease Cases

Condition

Number

Patients

Number

Units

Used

Deaths

Per

Cent

Deaths

Pneumonia

50.0

Typhoid

50.0

Meningitis

Tuberculosis

Unclassified

100.0

Total

- 9

44.4

The miscellaneous cases for which plasma was used
are analyzed in Table 9. A total of twenty-five patients
was treated with 40 units of plasma, with a death rate
of 8.0 per cent. This table does no more than illustrate

Table 9

Analysis

of Miscellaneous Cases

Number

Per

Units

Cent

Classification

Patients

Used Deaths

Deaths

Compound fracture

Debility .

Fortify liver ..

Cirrhosis of liver

2 1

100.0

Circulatory collapse

Cerebral apoplexy

Hemophilia

Epistaxis

... 5

Diabetic coma

Severe secondary anemia

Intestinal obstruction

9 1

16.6

Total

40 2

8.0.

July, 1946

225

further the variety of medical cases in which plasma is
a useful therapeutic agent.

No analysis can be made of the burn cases, since
reports did not give the degree or extent of injuries.
However, it can be pointed out, as listed in Table 1,
that thirty-six cases were treated with 1 12 units of plasma
and there have been notations on reports received indi-
cating that the use of plasma resulted in the saving of
lives.

Hewitt, s in 1941, stated that the more promptly the
protein and plasma loss can be stopped in burn cases, the
more likely is the patient’s chance of survival. In severe
or extensive burns, there is a marked loss of the fluid
which contains large amounts of plasma proteins. Blood
plasma is the quickest and easiest way to restore the
blood volume and cut down the severe hemoconcentra-
tion and protein loss. Because of the extensive hemo-
concentration, the transfusion of whole blood is contra-
indicated if plasma is available.

In 1940, Fraquio 9 presented a paper reviewing the use
of plasma transfusions. He states that indications for
plasma are numerous. In surgery, when time is impor-
tant, it is indispensable, and in shock with a condition
of hemoconcentration, large quantities of plasma are
beneficial. The author further states that in hepatic dis-
orders, plasma transfusions are given to maintain pro-
tein levels and that plasma can be used in all edemas
from the nutritional to the hypoproteinemic type. Plasma
therapy is successful in treating gastrointestinal hemor-
rhages, gastric and duodenal ulcers and lesions of the
large intestine. In the past few years the further ra-
tionale for the use of plasma in transfusion has been
well established by many workers.

Reactions Reported

Each unit of dried plasma sent out from the process-
ing laboratory includes a blank on which the physician
reports the final dispensation of the product. This blank
not only requests information regarding the use and
benefits derived from plasma, but also regarding the
reactions, if any, which occur during administration.
Unfortunately, the type of reaction is not reported,
that is, whether it is of pyrogenic, urticarial, or hemo-
lytic origin. Reactions are merely reported as moderate
or severe.

Table 10 gives the number of reactions reported on
the basis of the first two thousand reports. In this series,
fifty-one reactions were reported, a reaction rate of 2.55
per cent. Miller and Tisdall 10 reported a reaction rate
of 2.96 per cent in a series of 10,000 pooled liquid
plasma transfusions. In an excellent discussion of the
types of reactions from the administration of liquid
plasma, these authors divided the reactions into two gen-
eral classes, thermal and allergic.

Of the total number of reactions reported, forty-one,
or 80.4 per cent, were of a mild type and ten, or 19.6
per cent, were of a severe type. There were no fatalities
or near fatalities reported as attributable to plasma trans-
fusions. Of the total of 1,065 patients who received
plasma, forty, or 3.7 per cent, experienced some type of
reaction.

A small number of reactions may be expected in the

intravenous administration of fluids; however, with cau-
tion the reaction rate with plasma can be kept at a low
level. It is felt by the author that the reaction rate on
the next two thousand reports will be lower, based on
the fact that a majority of the reactions reported oc-
curred in the first thousand units used.

Table 10 also shows a very interesting fact regarding
the number of pools of plasma involved in the reactions
reported. Of the fifty-one reactions reported, the plasma
was from forty-four pools. It is further noted that
thirty-nine of these reactions, or 88.6 per cent, were from
individual pools. All other reports received on units of
plasma used from these pools gave no reaction. Only
three pools, or 6.9 per cent, gave two reactions, and two
pools, or 4.5 per cent, gave three reactions. These fig-
ures are good evidence that the reactions obtained are
not due entirely to the plasma.

Table 10
Reactions Reported

Total number of reports . 2000

Number of reactions reported 5 1 2.5 5%

Moderate reactions 41 80.4 %

Severe reactions 10 19.6 %

Number of patients receiving plasma 1065

Number of patients experiencing reaction 40 3.7 %

Number of pools involved . 44

Pools having only one reaction 3 9 88.6 %

Pools having two reactions 3 6.9 %

Pools having three reactions 2 4.5 %

One of the most important factors involved in re-
actions is the preparation of the intravenous equipment.
Under the North Dakota program complete intravenous
administration sets are furnished with approximately 65
per cent of all plasma units distributed. The larger hos-
pitals furnish their own administration sets. It is a
known fact that reactions of the thermal type are largely
preventable if scrupulous care is observed in the prepa-
ration of all apparatus used in the processing of plasma
and the administration sets. This care is essential for
the prevention of pyrogen contamination. In our labora-
tories all distilled water is checked for pyrogens and
pilot bottles from each pool of plasma are checked for
toxicity before it is released for distribution.

There are certain types of allergic reactions which
cannot be prevented because of the protein nature of
allergies. In this series of reactions two patients experi-
enced three reactions with plasma from three different

Table 11

Analysis of Cases Showing Reactions

Classification

Type of Reaction:
Moderate Severe

Total

Patients

Involved

Postoperative shock

Postoperative hemorrhage

Traumatic shock with he

morrhage 2

Traumatic shock without
hemorrhage

Ectopic pregnancy

Postpartum hemorrhage

..... 10

Miscarriage

Burn

Hypoproteinemia

Infection

Obstruction of bowel

Internal hemorrhage _

..... . 1

Hemophilia

Ulcer wtih hemorrhage .

Total _

226

The Journal Lancet

pools, and five patients experienced two reactions with
plasma from ten different pools. These patients prob-
ably would have shown a reaction with any unit of
plasma injected.

Table 11 gives an analysis of the cases showing a
reaction. Examination of these figures shows that the
reactions were not confined to any one particular type
of medical case. The largest number of reactions was
obtained in cases of hypoproteinemia and postpartum
hemorrhage.

Conclusions

1. Plasma furnished under a state-wide program free
of charge will be utilized in an efficient manner by the
medical profession and plays an important role in civilian
life.

2. Plasma is used to good advantage as a therapeutic
agent in a large variety of medical cases.

3. A state-wide plasma program helps to save the lives
of many patients and makes convalescence smoother in
others.

4. Reactions from the administration of pooled dried
human plasma are fairly infrequent and usually of a
mild nature.

Bibliography

1. Strumia, M. D., et al. : Frozen and Dried Plasma for
Civil and Military Use. J.A.M.A., 116:21, 2378 (May 24),
1941.

2. Elliott, J.: Blood Plasma. South. Med. and Surg.,

98:643 (Dec.), 1936.

3. Tatum, W. L., Elliott, Jr., and Nesset, N.: A Tech-
nique for the Preparation of a Substitute for Whole Blood
Adaptable for Use During War Conditions. Mil. Surg.,
18: 481 (Dec.), 1939.

4. Strumia, M. M., et al.: The Use of Citrated Plasma in
the Treatment of Secondary Shock. J.A.M.A., 114:1337
(April 6), 1940.

5. Tisdall, L. H.: Plasma in Obstetrics. Am. J. Obst. and
Gyne., 42:5, 889 (Nov.), 1941.

6. Ward, G. R.: Ed. Letter, Brit. M. J., 1:301 (Mar. 9),
1918.

7. Rous, P., and Wilson, G. W.: Fluid Substitutes for
Transfusion after Hemorrhage. J.A.M.A., 70: 4 (Jan. 26)
1918.

8. Hewitt, W. R.: Treatment of Burns. J. Miss. St. Med.
Assoc., 38:6, 191 (June), 1941.

9. Fraquio, V. A.: Transfusion de Plasma Sanguineo. Bole-
tin de la Asociacion de Damas de la Covadonga, Vol. XI,
Nums 9, 10, 11, 12, p. 107, 1940.

10. Miller, E. N., Tisdall, L. H.: Reactions to 10,000

Pooled Liquid Human Plasma Transfusions. J.A.M.A.,
128: 12 (July 12), 1945.

STATISTICS ON PUBLIC HEALTH WORKERS

Data gleaned from public health reports published in May of this year concerning the
training program conducted by state health departments during the period 1936 to 1944 under
Title VI of the Social Security Act reveal the following items of interest concerning the states
of North Dakota, Montana, and Minnesota:

1. The five institutions most frequently selected by participants in the program were,
in the order named: University of Michigan, George Peabody College, and the Universities
of Minnesota, Vanderbilt, and Pennsylvania.

2. On an average, 6.3 persons were trained for each 100,000 inhabitants. Correspond-
ing ratios for the forty-eight states ranged from 1.5 in Ohio to 26.6 in North Dakota.

3. By professional category, the representation of physicians among all trainees from a
state ranged from 1.6 per cent in Montana to 47.1 in Alabama. Conversely, the percentage
of Montana’s trainees who were nurses was 95.2, in contrast to 22.2 for Alabama, and 18.3
for Puerto Rico.

4. Personnel outside the medical, nursing, and sanitation fields made up 50.9 per cent
of all those trained in North Dakota. That this proportion was exceptionally high is indi-
cated by the corresponding percentage for all States and Territories, 9.4. One brief course
in vital statistics, provided for clerks who were to carry on that activity in various parts of
the State, made up the training received by a majority of these "other” workers in North
Dakota.

COOPERATION OF SOCIAL SERVICE ASSOCIATIONS AND PUBLIC
HEALTH GROUPS IN DIAGNOSING TUBERCULOSIS EARLY

The main problem in the control of tuberculosis is that of early diagnosis. As the next
step, however, treatment should be provided without delay. It is the duty of the physician
to educate the patient and his family in the infectiousness of the disease and of the value and
necessity of immediate care. A patient may delay proper attention at home, postpone seeking
admission to the sanatorium or continue to work after the diagnosis because necessary home
adjustment has not been made. To meet these situations requires the cooperation of public
or voluntary social service and welfare associations and of public health nursing and medical
groups. If such problems are taken care of, patients will be prompted to accept medical
treatment as soon as the diagnosis has been made. The possibility of progression of the dis-
ease can then be diminished and the morbidity and mortality of advanced tuberculosis thereby
avoided. — "The Early Diagnosis of Minimal Pulmonary Tuberculosis,” I. B. Bobrowitz,
M.D., and Ralph E. Dwork, M.D.: The New England Journal of Medicine, Jan. 3, 1946.

July, 1946

111

Looking Ahead in Health Service

Ralph I. Canuteson, M.D.*

Lawrence, Kansas

Twenty-five years ago a group of men, stirred by
common interests, met in Chicago. They were par-
ticipating in the evolution of the health service as a rec-
ognized adjunct in progressive colleges. No longer could
the physical welfare of students be passed over as no
responsibility of college administrators. If education was
to be the tool for better living it could not concentrate
on the mind alone. This was the belief of this early
group, and so, feeling the need for common grounds for
discussion of the many problems they were encountering,
they drew up plans for our American Student Health
Association.

It must be a satisfaction to the members of that char-
ter group to witness the healthy growth of the Associa-
tion and the college student health movement along the
lines they proposed.

Considering the origins of individual health services,
one cannot fail to be impressed by the variety of basic
organizations, but all with similar aims, from which in
time by a process of cutting and fitting, our present col-
lege health service pattern grew. Actually today in com-
paring one health service with another, it is almost im-
possible to find identical twins. Neither do we find any
health service that will not fit, like a piece in a jig-saw
puzzle, into some definite area of the basic health pro-
gram plan, a plan approved by our organization and by
other groups interested in this field. This health service
blue-print did not then spring into existence spontane-
ously. Rather, it unfolded by process of trial and error
in response to specific needs for promotion and mainte-
nance of health of college students.

Oldest perhaps of the cornerstones of a health pro-
gram was physical education, and later its offsprings,
intercollegiate and then intramural sports. Apparently
this one activity did not satisfy the growing interest in
physical welfare of college students, and so the next
step was, almost simultaneously, the introduction of
classes in personal hygiene, forerunner of what we prefer
to call health education today, and emphasis on the fac-
tors making for healthful living or environmental
hygiene.

Perhaps the youngest and lustiest of the quartet of
promoters and guardians of health of college students
was the medical service, a relatively late-comer. In seme
colleges this was organized by the students themselves
to assure them protection against the hazards of having
no one to care for them in the relatively frequent epi-
demics of earlier years. In more colleges, however, the
health progtam originated with one of the other services.
In only a few late organizations was an over-all plan
introduced at one time. Provision for any type of pre-
paid medical care was a radical departure in the field
of medicine, and it was not immediately accepted as an

ethical procedure. The value in health promotion and
maintenance and in applied health education gradually
became apparent. However, even today there are some
colleges that avoid incorporating medical services, other
than the simplest first-aid and routine physical examina-
tions, into their college health program.

It is difficult to say what binds together these four
basic groups into a unified health program, but perhaps
the medical service, properly staffed, represents the hub
of the over-all plan. In no way does this reflect upon
the importance of the other participating groups, nor
does it assume that without one group a health program
cannot function. Recent experience with the wartime
physical fitness program, however, accentuates the neces-
sity of correlating all the tools we have in maintaining
satisfactory standards of health and functional perform-
ance.

And so our blue-print, with administrative approval
and sympathetic support, specifies that any factors affect-
ing the health, physical or mental, of college students
falls within the province of the college health program.
There may be no formal departmental organization in-
corporating the interested groups, but closest correlation
is essential to handle the everyday problems that are
present at the health service. Many of these problems
would not enter the office of a private physician. Many
of them need no therapy in terms of drugs, but they
need a type of therapy that is just as important and often
more productive of good than drugs.

To illustrate, take the case of a boy who decides to
quit college. He reports to his dean that he is making
this move because he doesn’t feel well. The dean, with
many years of experience behind him, is not satisfied
with the reasons given. He refers the boy to the health
service, where in the course of the consultation, and ex-
amination, it develops that the boy is physically healthy,
but is discouraged about his classwork, has few friends
and no recreation, and his living conditions are conducive
neither to good work nor reasonable comforts. The health
service refers him, with a record of his physical exam-
ination, to the guidance clinic, and arranges for him to
go to the physical education department for help in get-
ting into recreational activities, to the dean of men for
a change in living quarters and then back to the first
dean for re-arrangement of class schedule. This friendly
help encourages the boy to stay in school and he is soon
readjusted and doing well.

This simple example illustrates the need for utilization
on a cooperating basis of the many departments involved
in student health, the fact that it is unnecessary to have
them all incorporated in one large department when
free exchange is practiced, and the increasing part the
medical service plays in a college health program as an
advisory agent or clearing center for problems not usually

*President, American Student Health Association.

228

The Journal Lancet

considered medical and too early to fall into the psycho-
somatic group.

Forward movement is apt to be devious if we do not
pause occasionally for a backward look to help establish
our bearings. And so I have given this brief survey of
the evolution and aims of our present day health service
programs. Now I want to mention, just as briefly, some
of the areas in which we should concentrate more atten-
tion in these immediate years.

For want of a better term, public relations is used to
designate an activity that should be given attention. We
do not need to be shown the value of a health service
in a college organization, nor in the field of medicine.
We know that our work encompasses medical service,
that is a protection to individual students and to the
entire college population, and that it includes: aid in
physical development through physical exercise classes
and recreational activities; health education in formal
courses and through the media of physical education,
medical service and campus public-health; and guidance
in conjunction with departments set up for that pur-
pose, in private consultations on health problems and by
contributing health information to the over-all picture
necessary in advising a student properly.

But in the general medical profession, among college
administrators and educators, and even in groups doing
work not too far removed from ours, there is still con-
siderable lack of understanding about the value and
function of a college health service. This is not peculiar
to college health programs alone, but as in other fields,
acquaintance develops understanding and respect.

The most congenial cooperation among the interested
departments is possible in any school, and becomes a
necessity if full advantage is taken to provide an opti-
mum health program with a minimum of duplication
and confusion.

In the coming years we should, as individuals and as
an organization, direct efforts toward interpreting our
work as well as toward doing a good job.

The first world war provided an impetus for expan-
sion of college health programs. The information on the
state of health of young men was startling and aroused
public interest. Between the two wars public health and
health service groups moved steadily forward, often
against the inertia of subsiding public enthusiasm for
health. Again, data from the Selective Service examina-
tions whipped up a froth of interest and recriminations
culminating in establishment of a physical fitness pro-
gram that was only a temporary, inadequate substitute
for a long time program.

College health service staffs were depleted and in
many cases health services became almost nonexistent.
In the first postwar lull we can again take stock, and
we are encouraged by the things we find.

Many schools are organizing health service programs;
many others are reorganizing and restaffing. In this
period of return to peacetime status more attention is
being paid to health than in any other time in our his-
tory. It is true that not all proposals are timely nor are
they well thought out nor well received, but there is
interest in general improvement of health standards.

As we participate in this reorganization of college
health programs, it is extremely important to see that the
highest standards are maintained in staff appointments
and in service rendered. It is not sufficient to provide
the equal of service rendered elsewhere in the commu-
nity; as members of educational institutions we shoudl
set higher standards than the common level.

To maintain good quality staff members in any of the
divisions of the health program there must be enthu-
siasm for the work and adequate training for the position
on the part of the individual. In return, good working
conditions and opportunities for professional improve-
ment and advance must be offered. In the final analysis,
the department is only as good as the staff that runs it.

In the area of undeveloped opportunities in health
service, attention to the physically handicapped merits
more attention. With more careful ear and eye exam-
inations much could be done to reduce disability in these
functions. Return of an older age group that has been
subjected to unusual traumata to the ears accentuates
the need for more interest in the prevention and allevia-
tion of hearing defects. The least a college health serv-
ice can do in this line is maintain efficient hearing tests
and direct students with early hearing defects to special-
ists who are interested in preventive work. Health serv-
ices have long been interested in vision defects, but less
attention is paid to the ear.

Popular interest reinforces health service activities in
provision of help for young people with emotional prob-
lems. Again, the effects of the war and an older age
group on college campuses impress us more and more
with the urgency of high-class guidance and psychiatric
help as a basic part of the health program.

In the files of health services are gold mines of data on acute
illnesses and minor complaints much of which would be the
starting point in the study of degenerative diseases. Not infre-
quently we get a request for a record on a former student who
is now incapacitated with a disease in middle life and are inter-
ested to find that, in retrospect, there were physical findings that
now fit the present picture. Few health services are equipped to
make even limtied use of their old records and data. An op-
portunity exists for extensive use of this material in research.

On the side of administration of the health program come
the problems of organization and financing. Health services
have for many years provided prepaid medical care with consid-
erable success and many difficulties. In appraising changes in
medical practice, study of health service experience would be of
great help in setting up modified plans of medical service within
the realm of that considered ethical and not detrimental to the
progress of medicine.

The questions of health insurance to cover college health serv-
ice needs, and the extent to which faculty and employees enter
into a college health program, as in industrial medicine, await
answers in the very near future.

I could list other areas little developed in the health service
program, but these suffice to illustrate the opportunities still
before us. Health service programs are integral in a college or-
ganization. They have the opportunity to influence for the best
the student’s attitude toward development of good health and
toward the agencies that provide him with health education, pro-
tection against health hazards, and medical care. It is our duty
and opportunity to maintain the highest professional standards
in our relations with the college student so that his college
training will act as a yardstick for measuring his later attitudes
toward health practices.

July, 1946

229

Future Prospects for Physicians

Judith Grunfel

Bureau of Labor Statistics, U. S. Department of Labor

The health deficiencies of our population were brought
home to us during the war period when about 40
per cent of all men of military age were found to be
ineligible for military service because of physical and
mental disabilities. This shocking discovery has rein-
forced a growing realization that many Americans need
better medical attention. The requests for additional
physicians will come from many sources. Higher earn-
ings by the workers of the country will bring greater
demands for medical services. The Veterans Administra-
tion will underscore the need for medical care and doc-
tors. With these facts in view, it appears that the out-
look for physicians and medical students is very bright
indeed.

Despite this, it will not be easy for the people of this
country to get the kind of medical service which they
expect. For, though the medical profession in the United
States is the fourth largest among professional occupa-
tions, the long-term rate of increase in the medical labor
force has not kept pace with the increase in population.

The Bureau of Labor Statistics of the U. S. Depart-
ment of Labor recently completed a study of the med-
ical profession as it is at present and the outlook for this
profession in the near future. This study shows the in-
crease in the number of physicians as compared to the
increase in population, the geographic location of physi-
cians, the higher standards of the medical schools and
the number of medical students now in these schools.

During the three decades before the war, the number
of physicians increased more slowly than the total pop-
ulation of the country. The increase between 1910 and
1940 in the number of physicians was only 13.4 per cent
compared with a 43.2 per cent increase in population
over the same period. This decrease in numbers of physi-
cians relative to population is somewhat mitigated by
improvements in means of transportation which is of
particular importance in rural areas.

The relatively slow growth of the profession in the
three decades preceding the war resulted from the fact
that a large proportion of the graduates from accredited
medical schools were needed merely to replace those
dying or retiring. The proportion of physicians over the
age of 65 rose from 7.9 per cent in 1920, to 11.5 per
cent in 1940, and in the latter year nearly half the physi-
cians reported as actively employed were over 45 years
of age, the point beyond which the average patient load
begins to decrease.

Opinions vary in the medical profession with respect
to the number of physicians to be trained. Dr. Williard
C. Rappelye, former director of the Commission on Med-
ical Education, in hearings before a Senate Committee
in 1944, expressed the opinion that the number of physi-
cians available "is entirely adequate for the medical needs
of peacetime and that there is no justification for any
substantial increase in the output of the medical schools.”

On the other hand, there are those physicians who
feel just as strongly that there is a growing need for
additional doctors. They give expression to this view by
editorials such as appeared in the March 9, 1939, issue
of the New England Journal of Medicine which stated:

"It is sometimes claimed that the medical profession is over-
crowded. The proponent of this claim is usually a member of
the medical profession and the ground for the complaint is that
there are many doctors, far too many, who are not able to make
a comfortable living. If one employs in other fields the line of
reasoning which has led to this conclusion, one may well declare
that the United States, not to speak of the earth, is over-
crowded . . .

"From bare statistical comparisons with other countries one
might conclude, as has been done, that the United States has
too many doctors per thousand of population, and also by the
same token, too many telephones, too many automobiles, too
many bathtubs. It is a fact that no one knows how many physi-
cians there should be in the United States and any arbitrary
limitations might prove to be a serious mistake. Perhaps if
there were better physicians, even more would be needed to care
adequately for the population. Our health is far from perfect.”

There are wide disparities among the various parts of
the country in the number of physicians relative to pop-
ulation, not only as between States, but also as between
rural and urban areas. Furthermore, in a study made by
the U. S. Public Health Service it was shown that in
those States with the highest ratios of population to phy-
sicians, there was a considerably higher ratio of older
physicians with lower service capacity. This deficit of
younger physicians should be kept in mind in consider-
ing the population-physician ratios in the States in which
numbers of physicians were decreasing during the two
decades before the war. The table on the page follow-
ing this shows State population in relation to numbers
of physicians for 1920-1940:

The population-physician ratio ranged from 511 per-
sons per physician in the State of New York in 1940
to 1,635 persons in Mississippi. A major factor affecting
distribution of physicians is purchasing power as reflected
in income levels. In the four states with the lowest per
capita income, there were, on the average, 1,456 persons
per physician as compared with an average of 683 per-
sons in the six states with a per capita income of over
$800. Population-physician ratios are also more favor-
able in predominantly urban States than in predom-
inantly rural States with similar per capita income pay-
ments. Studies have revealed a striking increase in the
number of physicians practicing in urban centers and a
corresponding decline in the number engaged in rural
practice since the beginning of this century.

The availability of hospital facilities and proximity of
medical schools also affect the geographical distribution
of physicians. The eighteen States in which there were
no approved four-year medical schools up to July 1945
are, with some exceptions, at a disadvantage as compared
with five States at the top of the list which have twenty-
six approved schools. These five states had 42 per cent

230

The Journal Lancet

Table — State Populations in Relation to Numbers of Physicians, 1920-40

State

Percent of
increase in

Percent of
increase or
‘decrease in

Population per
physician

population,

1920-40

number of
physicians,
1920-40

1920

1940

Increase in populat ion, decrease in physicians:

Alabama

20.6

-17.9

1,036

1,523

Arkansas ..

11.3

-28.9

743

1, 161

Colorado -

19. 5

-7.3

530

684

Georgia -

7.9

-22.4

879

1,222

Idaho -

21.5

-14.0

900

1,271

Indiana -

17.0

-9.3

685

883

Iowa -

5.6

-17.9

674

867

Kansas

1.8

-18.7

696

871

Kentucky

17.8

-17. 1

785

1, 115

Maine .

10.3

-19.2

696

951

Mississippi ..

22.0

— 19. 4

1,081

1, 635

Missouri

11.2

-17.4

563

758

Nebraska

1.5

-18.8

667

834

Nevada

42.4

-5.9

506

766

New Hampshire.

10.9

-11.7

698

876

Oklahoma

15. 2

-15.3

767

1,043

South Carolina..

12.8

-7. 1

1,239

1,505

South Dakota

1.0

-22. 5

979

1,276

Tennessee..

24.7

-15.4

723

1,066

Vermont

1.9

-18.4

623

778

Wyoming

29.0

-12.7

748

1, 105

Increase in population, increase in physicians:

Arizona.

49. 4

+ 47.2

877

890

California..

1,01.6

+60.9

.503

630

Connecticut..

23.8

+44.6

803

688

Delaware.

19. 5

+ 20.7

811

803

District of Columbia.

51.5

+41.6

357

382

Florida

95. 9

+43. 4

677

925

Illinois

21.8

+7.6

604

683

Louisiana

31.4

+20.6

924

1,006

Maryland

25.6

+25. 1

616

619

Massachusetts

12. 1

+ 18.2

642

608

Michigan

43.3

+37. 7

821

855

Minnesota

17.0

+20.0

840

819

New Jersey

31.8

+68.8

901

704

New Mexico. ...

47.6

+ 1.2

854

1,245

New York . .

29.8

+ 55.9

614

511

North Carolina

39.6

+20.8

1, 197

1, 383

Ohio

19.9

+ .8

647

770

Oregon

39. 1

+ 12.4

631

781

Pennsylvania

13. 5

+ 13.6

765

Rhode Island . .

18.0

+25.3

817

770

Texas

37.6

+ 2.7

765

1,025

Utah..

22.5

+ 7.8

876

995

Virginia..

16.0

+9.6

962

1,018

Washington

28.0

+5.4

683

830

West Virginia...

29.9

+.5

8.50

1,099

Wisconsin

19. 2

+ 22.5

947

922

United States

24.6

+ 14. 2

729

796

1 Source: Census of Population 1920, Occupations; Census of Population 1940, United States Summary;
Vol. Ill, The Labor Force, Parts 3, 4, 5, Table 13. Percentages have been computed.

of the entire student enrollment in this country and 44
per cent of the graduates between June 1944 and June
1945. The extent to which availability of hospitals affects
location of physicians is illustrated by the fact that in
1939 there were only sixty-seven physicians per 100,000
population in counties without general or allied special
hospitals as contrasted with 157 for counties in which
there were 250 hospital beds or more. Construction of
modern hospital facilities in the numerous areas now
lacking them may offer attraction for considerably more
physicians, and persons planning to enter the profession
should bear this in mind.

Postwar Demand

Now what about the outlook for physicians for the
next few years? As was previously noted, the effective
demand for the services of physicians depends to a great
extent on income levels. If susbtantially full employ-
ment were achieved, the increase in the demand for phy-
sicians would be great. However, in this study made by
the Bureau of Labor Statistics, no attempt was made to
estimate the increase in the numbers of physicians re-

quired to meet the demands of the
population for medical services if full
employment were achieved. Instead,
allowance is merely made for the in-
crease in population from 1940 to
1950, on the assumption that the ratio
of the general population to the num-
ber of doctors serving it by 1950
would be no different from 1940.
To the extent that greater income
may mean increased demand for phy-
sicians’ services, the estimates pre-
sented herewith understate the pros-
pective effective demand.

The health deficiencies of the pop-
ulation shown by the findings of the
Selective Service doctors stimulated
considerable public interest in the pro-
vision of adequate medical service ac-
cording to need. Some of this interest
resulted in privately sponsored pro-
grams of financing medical care, in-
cluding prepayment plans, and pub-
licly sponsored health programs, in-
volving such suggestions as insurance
under social security, the further de-
velopment of preventive medicine, and
the construction of additional hospi-
tals, health centers and maternity
clinics.

The President in his message to
Congress on November 19, 1945, rec-
ommended Federal aid for construc-
tion of additional hospitals and health
centers within the reach of every com-
munity, expansion of public health,
maternal and child health services and
"facilities that are particularly useful
for the prevention of disease, mental
as well as physical,” Federal support of a broad program
to strengthen medical education and research; and finally
a system for general pre-payment of medical costs to
assure all Americans ready access to necessary medical,
hospital and related services. Should this program ma-
terialize, there will be large increases in the demand for
physicians in hospitals for civilians, in teaching, and in
medical research.

The importance attached to grants in the States for
construction of additional hospitals is reflected in pend-
ing bills. The manning of additional hospitals for civil-
ians planned during the war to be constructed after the
war was estimated to require 8,300 physicians. Plan-
ning by various private organizations for extension of
medical care through pre-payment schemes also points
to an increased demand for physicians.

The Servicemen’s Readjustment Act of 1944 author-
ized appropriations for expansion of the present hospital
facilities of the Veterans Administration, which will re-
quire additional physicians. The Veterans Administra-
tion will also require additional physicians for adminis-
trative work such as rating the extent of disabilities of

July, 1946

231

veterans for purposes of compensation and adjudicating
claims. A conservative estimate of the increase between
1940 and 1950 in physicians needed by the Veterans
Administration for all purposes is nearly 4,000.

In addition there will be a greater demand for physi-
cians for the armed forces. If the armed forces should
be maintained above 1940 levels, there would be an in-
creased need for physicians because of the lower ratio
of population to physicians kept in the armed forces.
There are no official estimates of the size of the postwar
armed forces to be maintained, but the number of physi-
cians needed may be suggested by the fact that between
12,000 and 16,000 physicians would be required to serve
2.5 million men, depending on whether peacetime or
wartime ratios are to be assumed. This indicates that
about 10,000 to 14,000 more physicians would be needed
after than before the war for the armed forces, if a mili-
tary establishment of that magnitude may be assumed.

The additional postwar demand for physicians arising
from medical care of veterans, expanded armed forces,
planned construction of new hospital facilities for civil-
ians, and population increase may be roughly estimated

as follows for about 1950:

Number of
Physicians

Veterans Administration 4,000

Expanded peacetime armed forces

(assuming 2,500,000) 10,000-14,000

Medical care for civilians at prewar levels,

allowing for growth in population 10,200

Extension of medical care above prewar levels,
staffing proposed new hospitals and health

centers for civilians 8,300

Total increase, 1940-50, in physicians needed 32,500-36,500

Supply in Relation to Additional Demand

In estimating the changes in the medical labor force
by 1950 as compared to that of 1940, it is necessary to
take into consideration the numbers trained and the re-

placement needs caused during the decade by deaths and
retirements of physicians.

An increase in graduations was made possible during
the war period by accelerated training and by deferments
of premedical and medical students from induction into
the armed forces; but the change in the deferment
policy affecting premedical students may have the ulti-
mate effect of reducing the number of graduates in 1948
and 1949. There were 36,197 graduates from approved
medical schools during the six academic years ending
June 1945. In addition, 18,202 freshmen, sophomores
and juniors were enrolled in the academic year 1944-45.
It is estimated that the total number of graduates from
1940 to 1950 will be from 55,000 to 60,000.

If one considers the fact that about 38,000 physicians
will either die or drop out of the profession because of
age during the ten year period, the net increase in the
number of physicians available for service will be between
17,000 and 22,000. The increase in demand over the
decade, conservatively estimated above at between 32,500
and 36,500 will therefore exceed the growth in the num-
ber of physicians by at least 10,500 under the most
favorable conditions and by more than 19,500 under less
favorable circumstances. Despite the limitations of any
estimate, the prospective deficit of physicians is bound
to assume considerable proportions, resulting from a
combination of long-term trends in the training and age
distribution of physicians, and the effects of the war on
demand and supply.

With an increasing ratio of older physicians, the out-
put of graduates from accredited schools in the prewar
decade exceeded deaths and retirements from the pro-
fession by not more than 1,000 each year. At prewar
rates of training it would take a number of years to
alleviate the situation, particularly in the twenty-one
states with rising population and decreasing numbers of
physicians between 1920 and 1940.

PENICILLIN AND SYPHILIS

Much remains to be learned about penicillin; its composition and mode of action, and
its ultimate place in the treatment of syphilis. Despite the most encouraging clinical evidence
of its very real value in sterilizing early lesions, and its great apparent usefulness against
syphilis in pregnancy, and central nervous system syphilis, it cannot yet be said that peni-
cillin is more effective than arsenical-bismuth therapy from the standpoint of producing
"cures”. Several years of observation on several thousands of patients treated under the vari-
ous schedules will be necessary before a dependable evaluation can be made. The experience
with penicillin species "K” emphasizes the interdependence of industry, laboratories, treatment
sources, and public and private agencies in promoting the control of syphilis. — Journal of
Venereal Disease Information.

232

The Journal Lancet

Biliary Obstruction in the Newborn with Recovery

Edmund C. Burke, M.D.
and

Erling S. Platou, M.D.

Minneapolis, Minnesota

The problem of biliary obstruction in the newborn
has become less obscure in the past decade. Since
1891, when this entity was first presented, the number
of cases reported has increased to nearly three hundred.
Of the treatment offered for congenital atresia of the
biliary tract in the newborn, only surgical intervention
has to date produced anywhere near satisfactory results.
No uniformly satisfactory treatment has been evolved
for the minority of cases of extrabiliary obstruction which
are due to an actual plugging of patent ducts. The dif-
ferentiation of anomalous conditions of the ducts from
those where only a mechanical plugging of the lumen
occurs has been difficult from a diagnostic standpoint.

Our object in presenting two cases of biliary obstruc-
tion in the newborn with recovery, is to offer a method
of differentiating a condition amenable only to surgical
intervention from one which can be corrected, in some
cases by medical treatment.

In some instances there exists a stenosis rather than
an atresia. The common duct becomes plugged with or-
ganized bile. In such instances the mere removal of the
plug producing the obstruction will return the infant
to normalcy.

Ylpp o has stated that bile pigments are absent from
biliary secretions until the fifth or sixth month of fetal
life, and from then on present only in small amounts.
Likewise, Strauss, Gross and Kyman 1 feel that in some
instances where jaundice is absent for a time and meco-
nium normal during the first few days after delivery,
the biliary tract must have been partially patent at birth.

Shortly before and after birth it is possible for viscous
biliary secretions in the fetus to become inspissated and
organized in atretic or inflamed biliary ducts and thereby
produce an obstruction. In this case it is theoretically
possible to effect a cure without surgical intervention.
The two cases presented seem to fall into this group.
The first case was reported by Alway and Platou in
1939.“

Report of Cases

Case 1. W. Me., male, 10 weeks old, was admitted
to hospital July 25, 1938, because of jaundice and failure
to gain weight. He was born five weeks prematurely
following the normal first pregnancy of a 32-year-old
mother. Both parents were healthy and had negative
serology. There was no history of jaundice in infancy
in either family. The birth weight was 5 pounds, 13
ounces. The placenta, vernix, and general physical ex-
amination were reported normal, but on the second day
after birth, jaundice was noted in the infant. This be-
came progressively more intense, and shortly before ad-
mission, assumed a greenish hue. Birth weight was not
regained for five weeks and at ten weeks, the infant’s
weight was 7 pounds, 12 ounces. The stools, which were

described as having been "greasy and almost white” since
birth, were passed three to four times daily. The urine
was said to be dark yellow and "foamy.” During the
first five weeks he was breast fed; for the next two weeks
he received one-half and two-thirds raw milk with dextri-
maltose and thereafter evaporated milk and Karo. In
the week prior to admission the infant became listless,
had frequent emeses and often refused its feedings.
Tremors of the arms and legs were noticed prior to
admission, but at no time was temperature elevation
discovered.

When admitted to the hospital, the baby appeared
greenish-yellow in color, had a marked loss of muscle
turgor and moderate dehydration. The deeply icteric
skin presented no petechiae, purpura, or other lesions.
The eyes were expressionless with deeply stained sclerae.
The nose, throat, ears, heart and lungs were found nor-
mal. The liver was enlarged and firm, the edge being
4 centimeters below the costal margin in the mid-clavicu-
lar line. The spleen was palpable but not large. Neuro-
logically nothing abnormal was noted. The striking phys-
ical signs were jaundice and athrepsia. The stools were
acholic and the urine stained the diaper brownish-yellow.
The temperature was normal and cultures of blood and
urine were negative. No evidence of infection could be
found.

On admission the hemoglobin was 60 per cent, leuko-
cyte count 12,000 with the differential of neutrophiles
34 per cent, lymphocytes 63 per cent, monocytes 2 per
cent. Erythrocyte fragility was normal. No erythroblas-
tosis was found at the time of admission or in subse-
quent examination. The bleeding time was 4 minutes,
clotting time being 4 minutes, 30 seconds. Icterus index
was 52 and the van den Bergh reaction was prompt
direct. On two occasions a four-day stool specimen
showed no bile pigment. Microscopic examination of the
stool with fat stain showed the greater portion to be
fat globules. Urinalyses were negative except for the
presence of urobilin. Both Mantoux and Wassermann
tests were negative.

During the 78-day period of hospitalization the in-
fant had several attacks of fever and diarrhea and was
almost moribund at times. The infant had alternate
periods of deep jaundice during which the stools were
moderately firm, and periods of severe diarrhea with
slightly less jaundice. The treatment was principally
dietary.

The diet consisted of low fat or fat-free milk with
calcium caseinate plus large doses of synthetic vitamins,
vitamin K included. Magnesium sulfate, egg-yolk, and
bile salts were given at intervals. Apple powder, when
added to the formula, was strikingly effective in control-
ling diarrhea. Five transfusions of about 50 cc. each were

July, 1946

233

given and intravenous glucose and parenteral fluids were
administered as indicated. Several times during the hos-
pital course, surgical intervention was considered but the
infant’s condition positively denied us such a risk.
Toward the latter part of his hospitalization the dietary
problem abated somewhat and banana and cereal were
tolerated. About this time the jaundice lessened in de-
gree, the stools became yellow and a four-day stool speci-
men showed an average of 700 milligrams of urobilino-
gen per day. The infant was discharged on September
10, 1938, weighing 1 1 pounds and 14 ounces. The jaun-
dice had disappeared almost completely, feedings were
tolerated well and diarrhea cleared up.

In the above case it was concluded that the obstruction
was produced by a plug of inspissated bile in the ducts.
Probably a stenosis was also present. The four-day stool
determinations were of considerable value in following
the course of the patient and the relenting of the ob-
struction. Surgery probably would have been under-
taken had it not been for the poor physical state of the
patient. During the period of intensive nutritional build-
up and following the test meal of magnesium sulfate-bile
salts-egg yolk, symptoms disappeared and the patient
showed remarkable recovery.

Case 2. R. B., a white male infant, was born May 13,
1945, one week prematurely, weighing 6 pounds, V)/z
ounces following spontaneous delivery. His condition
after delivery was good and he was apparently a normal
infant. No abnormalities of cord or placenta were noted.

During the eighth month of pregnancy the father had
contracted lues which was manifested by a second-stage
generalized eruption. He underwent intensive treatment
with penicillin which was effective. At no time did the
mother develop a positive Wassermann.

The infant’s hemoglobin (May 14) was 131 per cent,
or 22.2 grams, and 2 normoblasts per 100 white blood
cells were noted. The infant’s blood was Rh positive, as
was the mother’s.

On the 15th of May pufflness of the eyelids and a
short systolic murmur over the tricuspid area were noted,
but otherwise there were negative findings. On the 16th,
several cyanotic episodes were noted, the first of which
lasted 15 minutes, and following the second episode the
color remained poor. Continuous oxygen was adminis-
tered. Convulsive twitchings were occasionally noted
on the 17th. The hemoglobin was then 104 per cent,
or 17.5 grams. A blood sugar determination showed
230 milligrams per cent and a urinalysis gave the fol-
lowing findings: red cells 100-200, white cells, 10-25,
bile stained casts, of which one third were granular casts,
and an occasional cast of the cellular type.

Cyanotic spells continued to occur, the infant appeared
listless and on the 18th a small amount of blood was
present in the stool. An X-ray film of the chest failed
to support the diagnosis of a congenital heart lesion, but
an increase in bronchovascular markings resembling bron-
chitis was observed. Repeated urinalyses showed red
cells, white cells, and bile-stained casts. The hemoglobin
on the 19th was found to be 110 per cent, or 18.6 grams.

Feedings consisted of nursery formula supplemented by
the subcutaneous administration of Hartman’s solution.
The patient’s weight reached a low of 6 pounds, 2
ounces, the fourth day following delivery. On the 22nd,
the urine was grossly bile-stained, contained red cells,
2-4, pus cells, 8-10, and occasional granular casts. A
urine culture on the 24th reported Staphylococcus albus,
pneumococci, and occasional short-chained nonhemolytic
streptococci. The urine continued to show the presence
of bile. The patient had not shown any elevation of
temperature to date. The skin showed a generalized
vesicular eruption but no icterus was noted.

On the 25th the child was very flaccid and had a gen-
eralized vesicular eruption, more marked on the neck.
The extremities were edematous. The pharynx showed
a residual pharyngitis with marked injection of the lower
tonsillar poles. The liver and spleen were slightly en-
larged. The conclusion reached at this time was a sys-
temic infection with attendant pyelonephritis.

The throat culture revealed a staphylococcus albus
organism. Subsequent urinalysis showed the urine to be
free from red and white blood cells, but bile was still
present in the urine. The Kline test was negative and
X-rays of the long bones for lues were negative. June
3rd it was noted that the sclerae were icteric and on
the 9th the skin was observed to have an icteric hue.
Hepatitis was suspected and bile was found in the urine
in increasing amounts. A trace of albumin was likewise
found on periodic urinalysis.

Plasma was given intravenously, and fortified Hart-
man’s solution was given subcutaneously. Glucose, 10
per cent in normal saline, was given orally between feed-
ings. Immune globulin, 0.8 cc., was given intramuscu-
larly. Stools were creamy-colored but the patient’s con-
dition improved, bile disappeared from the urine and he
was discharged on the 19th weighing 8 pounds, /j ounce,
though some icterus persisted.

The patient was readmitted on June 25th with a his-
tory of daily temperature of 100° rectally. The physical
examination at this time showed a very icteric six-week-
old child, temperature of 101.2° rectally, in a moderately
good state of nutrition. No deformities were observed
except a hemangioma on the scrotum approximately 0.75
centimeter in diameter. The liver was palpable 1 to 1.5
centimeters below the right costal margin. The spleen
was just barely palpable in the left upper quadrant. The
remainder of the physical examination revealed no con-
tributory findings. The urine was grossly dark-colored
and the stools were soft, yellow, and foul smelling. The
hemoglobin was 89 per cent and the leukocyte count
was 18,000.

The icterus index on the 25th was 140. The qualita-
tive van den Bergh showed a prompt direct reaction,
75 per cent of the maximum color developing in one
minute. Blood cultures were negative.

The patient was given nursery formula supplemented
with Hartman’s solution and vitamins. Penicillin was
given intramuscularly, 2000 units stat. and 500 units
every two hours. Immune globulin was given intramuscu-
larly on July 16th and daily for five days.

The cephalin-cholesterol flocculation test was negative.

234

The Journal Lancet

The serum bilirubin (on July 19th) was reported at
13.3 milligrams; prothrombin time was 18.6 seconds, the
control being 16.5 seconds. The four-day stool collec-
tion showed 1.7 milligrams of urobilinogen per 100
grams of stool. The serum bilirubin on August 6th was
reported as 4.8 milligrams per cent.

At this time before resorting to surgery, 2 drams of
50 per cent magnesium sulfate followed in half an hour
by a raw egg yolk and 5 grains of Fel Bovis were given
on a fasting stomach via gavage. This treatment was
repeated on July 28th and August 3rd, and additional
laboratory data were obtained. The serum bilirubin fell
to a total of 6.2 milligrams per cent on July 30th and
a subsequent four-day stool specimen showed 9.7 milli-
grams of urobilinogen per 100 grams of stool. The
serum bilirubin on August 6th was reported as 4.8 milli-
grams per cent.

The patient was discharged on August 9, 1945, weigh-
ing 9 pounds, 8 ounces. Since discharge his course has
been uneventful and a complete recovery is indicated by
his entirely normal state six months later.

In the second case it is noted that the course was made
more complicated by the early appearance of pyelo-
nephritis which led us to suspect a hepatitis. Later, how-
ever, the patient’s course resembled that of an extrabiliary
obstruction. Again, with laboratory aids and the use of
the cephalin-cholesterol flocculation test of Hanger 3 the
diagnosis of an obstruction became more feasible.

The chart shows graphically the relation of the fall of
the serum bilirubin to administration of the test meal.

■a

\T>

Before surgery was to be attempted, the patient’s phys-
ical state was improved by a dietary regimen, parenteral
fluids and large dosages of vitamins. The idea of a test
meal was fostered as a last resort before surgical inter-
vention and results were startling. The serum bilirubin
decreased and the output of feces urobilinogen increased.
The magnesium sulfate-egg yolk-bile salts meal was re-
administered several times and recovery followed a course
of continual improvement.

The cholagogue action of the egg-yolk and bile salts,
together with the smooth muscle response produced by
the magensium sulfate, were perhaps of some aid in
bringing about the release of the obstruction.

In infants with congenital obstruction of the biliary
tract the icterus may or may not be noted from birth.
The absence of jaundice after birth with normal meco-
nium may be due to ducts that are at least partially
patent at birth. As contended by Ylppo, however, the
reason for the late onset of jaundice may be the small
amounts of bile pigment elaborated. If the capacity of
the liver for storage of bile pigment has been exceeded,
jaundice results.

Stools, usually acholic, may at first contain bile be-
cause of passage through deeply stained intestinal walls.
Hicken and Crellin 4 state that the presence of bile in
the stools need not preclude the patency of bile ducts
but may be the result of cholemic blood oozing from
intestinal, walls. The quantitative urobilinogen in 100
grams of a four-day stool specimen may drop below
5 milligrams in an obstruction such as might be found
in carcinomatous obstruction. Watson 5 has made use of
this relationship of the amount of urobilinogen in the
stool to the degree of obstruction in aiding the diagnosis
as to cause of the obstruction. Accepted normal values
and variations are listed in the table.6

Table

Fecal Urinary Urinary

Urobilinogen Urobilinogen Bilirubin

Normal:

Adult

Infants, to 2 years
Children, 3-11 years
Hemolytic Jaundice
Obstructive Jaundice
Hepatogenous Jaundice

50-250 mg. 1-2 mg. /day None
per day

2.5 mg./day

2.6 mg./day

Increased Increased None
Trace or none None Increased

Trace, normal Trace, normal Increased
or positive or positive

The urine is dark-colored due to the presence of
large amounts of urobilinogen and the presence of bile
pigments may be detected by any of the various tests
available. A prompt direct van den Bergh test is believed
by Watson to be a valuable indicator of early escape of
pigment through the kidneys. The one-minute van den
Bergh test was found to be more significant than the
later (15-minute) results. In some patients a low thresh- i
old for the pigments must be suspected . Occasionally, 1
the morning urine specimen may show the presence of
bilirubin while later specimens will fail to show the pres- ;
ence of the pigment.

Laboratory adjuvants in the study of jaundice in in-
fants are many. The usual urinalyses and feces determi-
nation for detection of bile pigments are necessary. Other
laboratory aids in diagnosis are: serum bilirubin, icterus
index, van den Bergh determinations, direct and indirect,
the four-day stool quantitative determinations for uro-
bilinogen and also of considerable importance is the
cephalin-cholesterol flocculation test of Hanger. A more
recently developed test is the thymol turbidity test. The
thymol turbidity test is based upon the concept that glob-

July, 1946

235

ulins are precipitated more or less readily by phenolic
compounds. Thymol has been found the most satisfac-
tory of any of a number of phenolic compounds tested.
(A saturated aqueous solution of thymol buffered with
barbitone and sodium barbitone to a pH of 7.8) .

The degree of turbidity is measured after half an
hour with formazin standards devised by Kingsbury and
associates. Normal sera ranges from 0-4 units. The
test offers several advantages not available through the
use of the cephalin-cholesterol flocculation test, namely,
simplicity and the short time required for the completion
of the test.

Watson and Rappaport 7 compared the Hanger test
with the Maclagen test in liver diseases. These workers
concluded that the Maclagen thymol turbidity test was
a reliable and simple test of liver function and in the
majority of cases directly paralleled the Hanger test.

The van den Berg test in obstruction of the bile ducts
is positive, direct, and not biphasic. The quantitative
urobilinogen in normal stool varies from 40-280 milli-
grams per day and in an obstruction of the bile ducts
the values may fall nearly to 0 milligrams depending on
the amount of obstruction existing.

The Hanger cephalin-cholesterol flocculation test de-
serves particular emphasis in the study of obstruction of
bile tracts. Hanger demonstrated that emulsions of
sheep brain cephalin and cholesterol are flocculated by
the sera of jaundiced patients with hepatocellular dam-
age. Some investigators discredit the value of the Han-
ger test in the differential diagnosis of various types of
jaundice. Nadler and Butler 8 have concluded that the
determinations give negative results in normal individuals
and rarely, if ever, positive results in patients without
hepatic diseases. They feel that this test is a more sen-
sitive indicator of active liver parenchymatous disturb-
ance than are the various liver function tests and that
the cephalin-cholesterol flocculation test is the best avail-
able indicator in the prognosis of hepatic disease.

Hanger’s test is of particular significance in the dif-
ferentiation of congenital obstruction from the obstruc-
tion produced by hepatitis of infectious origin. Cases of
jaundice due to congenital obstruction of the extrahepatic
ducts give negative or faintly positive results, while those
cases of jaundice associated with hepatitis show strongly
positive reactions.

The flocculation test mechanism probably depends
upon the capacity of an altered globulin constituent of
serum to become affixed to colloidal elements of the
emulsion. In hepatocellular disease associated with an
obstruction, flocculation fails to occur because of the ina-
bility of the fixation of serum globulin factors to the
colloidal elements. The thymol turbidity test is believed
by some investigators to be even more delicate.

We wish to emphasize the value of these tests in diag-
nosis and urge preliminary trials of a test meal of mag-
nesium sulfate-egg yolk and bile salts. The test meal
can be used in cases diagnosed as congenital obstruction
of the bile ducts with the hope that an obstructive plug
may be removed from the ducts. The test meal is given
by gavage on a fasting stomach. The 50 per cent solu-

tion of magnesium sulfate should be given before the
egg yolk-bile salts mixture. Approximately 2 drams of
magnesium sulfate will suffice. The egg yolk is given
raw after testing and the dosage of bile salts is 15 grains.
The test meal may be repeated if necessary but the
course of the patient should be followed by repeated
laboratory procedures, as previously mentioned. An in-
creased output of feces urobilinogen and a fall in the
serum bilirubin is the indicator of relenting obstruction.

If, after several attempts, the results are not indica-
tive of the release of obstruction, surgical intervention
must be undertaken as soon as possible. Ladd 9 advises
surgical intervention before the fourth month because
of the possibility of error in diagnosis and if congenital
obstruction of the bile ducts does exist, time may and
should be taken to reach high nutritional levels in these
patients. The mortality without operation is 100 per
cent except in that type of case which we have pre-
sented, namely, obstruction due to inspissated bile.

Some cases with obstruction due to a plug of bile in
the ducts will prove refractory to medical treatment and
it is for these cases that Ladd advises use of the simple
technique of injecting saline into the gallbadder and
distending the ducts. This enables identification of tiny
structures as well as the possibility of removing bile plugs
and debris from the ducts.

Hicken and Crellin have placed emphasis on the tech-
nique of cholangiography. This can be carried out in a
manner similar to that employed at operation on adults.

Conclusions

1. Two cases of biliary obstruction in the newborn with re-
covery are presented.

2. In both cases obstruction was attributed to a plug of in-
spissated bile.

3. Cephalin-cholesterol flocculation tests have been used as
adjuvant to the diagnosis of congenital obstruction of the bile
ducts in the newborn. The thymol turbidity test is mentioned
as a recent development in detecting liver impairment.

4. The use of magnesium sulfate-egg yolk-bile salts test meal
was thought to contribute to diagnosis and recovery.

Bibliography

1. Strauss, A., Gross, Jr., and Kyman, S.: Congenital Atre-
sis of the Common Bile Duct; case report. Ann. Surg.,
117:723-727, 1943.

2. Alway, R. H., and Platou, E. S.: Biliary Obstruction in
the Newborn with Recovery. Minn. Med. 22: 707-708, 1939.

3. Hanger, T. M.: Serological Differentiation of Obstruc-
tion from Hepatogenous Jaundice by Flocculation of Cephalin
and Cholesterol Emulsion. J. Clin. Investig. 28: 261, 1939.

4. Hicken, N. F., and Crellin, H. G.: Congenital Atresis
of the Extrahepatic Bile Ducts. Surg., Gyn. and Obst.,
71:437-44, 1940.

5. Watson, C. J.: Regurgitation Jaundice; Clinical Differen-
tiation of Common Forms, with Particular Reference to Degree
of Biliary Obstruction. J.A.M.A., 114:2437, 1940.

6. Platou, R. V., and Nadler, S.: Jaundice in Infancy and
Childhood. Journal Lancet, Vol. LXV, No. 5, p. 188, 1945.

7. Watson, C. J., and Rappaport, Capt. E. M.: A Compari-
son of the Results Obtained with the Hanger Cephalin Choles-
terol Flocculation Test and the Maclagen Thymol Turbidity
Test in Patients with Liver Disease. J. of Lab. and Clin. Med.,
Vol. 30, No. 12, pp. 983-992, 1945.

8. Nadler, S. B., and Butler, M. E.: Cephalin Cholesterol
Flocculation Test in Jaundiced Patients. Surg., 11:732-738,
542.

9. Ladd, W. E.: Congenital Obstruction of the Bile Ducts.
Ann. Surg., 102: 742-751, 1935.

236

The Journal Lancet

. . . fUEET OUR COflTRIBUTORS . . .

Dr. Winfred W. Arrasmith of Casper, Wyoming,
has practiced there for eight years. His specialty is in-
ternal medicine. He is a graduate of Iowa State Uni-
versity (B.S.), and Northwestern University Medical
School, Chicago, (M.D., 1922), with graduate work at
the Annual Clinics, American College of Physicians,
since 1928. He is a fellow of the American College of
Physicians, diplomate of the' American Board of Internal
Medicine, member of the American Medical association,
and Wyoming State Medical association.

Dr. Ralph I. Canuteson is president of the Ameri-
can Student Health association, and director of the Uni-
versity of Kansas health service at Watkins Memorial
hospital, Lawrence, Kansas. He is also vice-president of
the Kansas Tuberculosis and Health association, and
member of the American Medical association, Kansas
Medical society, American Public Health association,
American State Hospital association, American Trudeau
society, and Mississippi Valley Conference on Tubercu-
losis. His newest office is chairman of Planning Commit-
tee, Third National Conference on Health in Colleges.

Dr. Melvin Koons of Grand Forks, North Dakota,
has been with the North Dakota State Health depart-
ment for twelve years and associate professor of public
health at the University of North Dakota since 1942.
Dr. Koons was a contributor to the January 1946 issue
of Journal Lancet.

Dr. Erling Platou, well-known Minneapolis pedia-
trician, and clinical professor of pediatrics at the Univer-
sity of Minnesota, was special editor of the May 1946
issue of Journal Lancet.

Dr. Edmund C. Burke, who has been assistant to
Dr. E. S. Platou, is a recent graduate of the University
of Minnesota Medical School with degrees of B.S.,
M.B., and M.D. He was a pediatrics resident at North-
western hospital for nine months. He is soon to enter
military service in the Medical Corps of the Army.

Miss Judith Grunfel is Chief of the Professional
Occupations section, Bureau of Labor Statistics, U. S.
Department of Labor, Washington, D. C. She is an
economist, Ph.D., and has contributed to many distin-
guished economic and social science periodicals.

Dr. Oliver E. Sarff, of Minneapolis, was graduated
from the University of Minnesota in 1928 with degrees
of B.S., B.M., and M.D. He did graduate work at the
Minneapolis General hospital and the University of
Iowa. His specialty is urology. He is a member of the
Hennepin County Medical society, Minnesota State
Medical association, and American Medical association.

Dr. James C. Healy, acting head of the Department
of Pharmacology, Tufts Medical School, Boston, Massa-
chusetts, was graduated from this College in 1927 with
degrees of Ph.G. and M.D. He has practiced in Boston
for 15 years and his specialty is immunology. He is a
member of the Massachusetts Medical Society.

Book JlevUws

Ambulatory Proctology, by Alfred J. Cantor, M.D. Cloth.
513 pages. 281 illustrations. New York: Paul B. Hober,
Inc. $8.00.

Ambulatory Proctology is a most difficult book to review
since there is so much in the text to confuse the reader. The
Preface to the text has been excellently written and presents a
clear picture to the reader of the specialty of proctology and of
the author’s conception of what the specialty should be.

Had the author chosen a title for his book other than AM-
BULATORY Proctology, much of the confusion would not
arise. Dr. Beaumont S. Cornell, who has written the Foreword,
asks the reader to note the author’s definition of "ambulatory”.
The author then defines ambulatory proctology as any surgery,
minor or major in character, after which the patient may, with-
out undue risk, leave the office. The author does not state to
which destination the patient is to go after leaving the office
but the reader must assume that it is the patient’s home. The
author then proceeds to cover the field of rectal and bowel path-
ology and the treatment thereof.

It is inconceivable that Dr. Cantor would wish to create the
impression that it is feasible or even possible to send a patient
home after doing an extensive resection of the coccyx and
sacrum for a rectal tumor or that it would be well to treat a
patient anywhere except in a hospital for an extensive cellulitis
and "phlegmon” of the pelvis, erysipelas, retrorectal or pelvi-
rectal abscess or after the surgery incidental to an extensive peri-
rectal fistula. Not only will the man with experience be con-
fused upon reading these statements, but the beginner is apt
to be led astray.

In the paragraphs on anatomy, the author’s enthusiasm takes
him beyond his subject and carries him into a discussion of
pathology. The chapter on diagnosis is very sketchy and in-
complete. Dr. Cantor has wisely included a chapter on Pediatric
Proctology. This chapter is well done but it is certain that defi- j
nite exceptions could be taken to some of the ideas expressed.

In the chapter on pruritus ani, the author is again carried
away by his enthusiasm for the tattoo treatment accompanied
by anal neurotomy. The chapter on the injection treatment of
hemorrhoids is very well written and covers the subject in an
excellent manner.

Ambulatory Proctology has a definite place in the library of
the proctologist. It is not a book to be recommended to the
beginner or to the general practitioner who occasionally treats
rectal disease. W. B.

AMERICAN STUDENT HEALTH ASSOCIATION

Dr. Mary Fisher DeKruif, for many years Director
of Student Health, Wellesley College, Wellesley, Massa- j
chusetts, died on May 8, 1946.

Dr. Edgar Fauver, for many years Director of Phys-
ical Education and later University physician at Wes-
leyan University, Middletown, Connecticut, died on
April 8 of this year.

Dr. Dana L. Farnsworth, Director of Student Health '
at Williams College, has been appointed to the post of
Director of the Medical Department at Massachusetts j
Institute of Technology. His duties there start in Sep-
tember of this year.

Dr. Robert R. Snook has been appointed Director of
the Student Health Service at Kansas State College,
effective February 1, 1946, to succeed M. W. Husband,
M.D., who resigned.

JOURNAL

la?§cet

Serves the Medical Profession of

MINNESOTA, NORTH DAKOTA, T SOUTH DAKOTA and MONTANA

North Dakota State Medical Assn.

Dr. A. E. Spear, Pres.

Dr. Philip G. Arzt, Pres. -Elect
Dr. L. W. Larson, Secy.

Dr. W. W. Wood, Treas.

North Dakota Society of
Obstetrics and Gynecology
Dr. E. H. Boerth, Pres.

Dr. Paul Freise, Vice Pres.

Dr. G. Wilson Hunter, Secy . -Treas.

Minneapolis Academy of Medicine
Dr. Karl W. Anderson, President
Dr. Russell W. Morse, Vice Pres.

Dr. J. C. Miller, Secretary

Dr. Ragnvald S. Ylvisaker, Treasurer

Dr. Henry E. Hoffert, Recorder

ADVISORY COUNCIL

South Dakota State Medical Assn.
Dr. F. S. Howe, Pres.

Dr. H. R. Brown, Pres.-Elect
Dr. J. L. Calene, Vice-Pres.

Dr. Roland G. Mayer, Secy.-T reas.

South Dakota Public Health Assn.
Dr. J. M. Butler, Pres.

Dr. C. E. Sherwood, Vice Pres.
Dr. Gilbert Cottam, Secy.-T reas.

Sioux Valley Medical Assn.

Dr. D. S. Baughman, Pres.

Dr. Will Donahoe, Vice Pres.

Dr. R. H. McBride, Secy.

Dr. Frank Winkler, Treas.

BOARD OF EDITORS

Dr. J. A. Myers, Chairman

Montana State Medical Assn.

Dr. S. A. Cooney, Pres.

Dr. M. A. Shillington, Pres.-Elect
Dr. R. F. Peterson, Secy.-T reas.

Northwestern Pediatric Society
Dr. G. B. Logan, Pres.

Dr. Geo. Kimmel, Vice Pres.

Dr. Northrop Beach, Secy. -Treas.

Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.

Dr. R. C. Webb, Secy. -Treas.

American Student Health Assn.

Dr. Ralph I. Canuteson, Pres.

Dr. Glenadine Snow, Vice Pres.

Dr. G. T. Blydenburgh, Secy.-T reas.

Dr J . O. Arnson
Dr. A. B. Baker
Dr. D. S. Baughman
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W . A. Fansler

Dr. A. R. Foss
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. J . Mabee

Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C H. Nelson
Dr. N. J. Nessa
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. C. E. Sherwood

Dr. M. A. Shillington
Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. S. E. Sweitzer

Dr. W, H. Thompson
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H M N. Wynne
Dr. Thomas Ziskin,

Srcr nary

LANCET PUBLISHING CO., Publishers, 84 South Tenth Street, Minneapolis 2, Minnesota

Minneapolis, Minnesota, July, 1946

STRENUOUS HOLIDAYS

Americans as a whole are an aggressive people.
Whether it is a "hangover” from the necessities of our
pioneer struggles for existence during the early days of
this country we do not know, but certain it is that the
tempo continues in high gear in spite of our present con-
dition of comparative opulence.

In other countries when a train reaches its destination
and comes to a stop at the station, that’s when the pas-
sengers get up and walk out. With us, you may have
noticed, they begin to huddle at the end of the coach
as soon as the city limits are discernible from a distance.
We are so eager to be fast, big and first. A motor race
is of no interest unless a previous record is smashed and
a life or two sensationally sacrificed in the attempt. It
would seem equally appropriate that many of our mod-
ern entertainments should begin as in days of old with
the gladiator’s "We who are about to die, salute you.”
Men of different nationalities were asked to write some-

thing about the elephant. The German wrote a scientific
dissertation of six volumes on the biology of the elephant.
The Frenchman wrote about the elephant’s love life.
The Englishman wrote on hunting the elephant. The
American wrote on how to grow bigger and better
elephants.

Before fireworks were outlawed in these parts, every
Fourth of July celebration had to be bigger and better
than the preceding one, and in consequence each was
more destructive to many unfortunate participants. The
prediction was made by the National Safety Council
from the Chicago headquarters that there would be 130,-
000 casualties from the celebration of the Independence
Day this year. We have every reason to assume that they
will turn out to be bigger but not better. The elimina-
tion of fireworks alone cannot stop the carnage. Let us
hope that the safety council may be successful in direct-
ing the holiday spirit of the future into paths of saner
celebration. A. E. H.

237

238

The Journal Lancet

VACCINATION AND TUBERCULOSIS

Recently in some parts of the country the lay press
presented statements concerning promise afforded by
BCG in the control of tuberculosis. Probably this will
result in large numbers of persons making inquiries from
their physicians concerning vaccination against tubercu-
losis. BCG (bacillus Calmette-Guerin) is a living bovine
type of tubercle bacillus which Calmette planted on ox-
bile-potato medium in 1908. By 1921 this strain had
been transplanted 230 times, and was thought to have
become so avirulent that it would not produce progres-
sive tuberculous lesions in the tissues of animals or hu-
mans. However, this organism still liberated tuberculo-
protein and so sensitized the tissues as to cause charac-
teristic reactions to tuberculin.

BCG was first administered to cattle by Calmette and
Guerin in 1913. When the experiment was concluded,
three of the control and two of the vaccinated animals
had developed tuberculosis of clinical significance. In
due time the United States Bureau of Animal Industry
conducted experimental work with BCG on a large scale
and under well controlled conditions on the cattle of
America. By 1931 two of the Bureau’s expert scientific
workers reported that every vaccinated, as well as every
control animal, contracted tuberculosis in each of three
experiments. There was very slight, if any, difference in
the character and extent of the tuberculous lesions in
favor of the vaccinated animals over the controls. They
said: "These results corroborate the Bureau’s previously
published findings and demonstrate that the use of BCG
does not prevent animals from contracting tuberculosis
when exposed and that lesions, once established, do not
tend to resolve.”

Special committees on tuberculosis of the American
Veterinary Medical Association and the United States
Livestock Sanitary Association issued reports in 1931,
similar to those of the Bureau of Animal Industry. In
1934 Watson, of Ottawa, Canada, summarized the re-
sults of his ten years of experimental work with BCG
among cattle, which showed that the incidence of tuber-
culosis in the aggregate was exactly the same in the vac-
cinated and unvaccinated animals. The lesions of the
vaccinated cattle showed a marked tendency toward
caseo-purulent and exudative processes with appreciably
less fibrosis than in the unvaccinated group. Dr. W. P.
Larson, Chief of the Department of Bacteriology of the
University of Minnesota, conducted a large experiment
on cattle and reported in 1929 that BCG has no value
whatsoever in controlling tuberculosis among cattle. One
of America’s most famous veterinarians, Van Es, pointed
out that BCG did not appear to be the solution of the
tuberculosis problem among animals. He said that all of
the various methods of vaccination proposed are of Eur-
opean origin, and to a large extent these many efforts
and continued search for an immunization method reflect
the desperate nature of the tuberculosis situation in west-
ern Europe.

Thus, in Canada and the United States extensive ex-
perimental work was done among cattle where the results
could be determined at will by postmortem examination,

and they were such that BCG was completely discred-
ited and discarded. The vaccine was not only proved to
be of no value but served as a definite deterrent in con-
trolling tuberculosis among cattle because it rendered
useless the tuberculin test, the most valuable weapon in
tuberculosis control among cattle.

After discarding BCG, the veterinarians of Canada
and the United States continued with the fundamental
procedures which they had previously found so effective,
namely, identifying all animals that react to tuberculin
and eliminating them from the herds so as to prevent
contagious cases from developing. This was so effective
that in November 1940 the entire United States was
accredited with reference to tuberculosis among cattle.

Soon after Calmette’s original experiment with BCG
among cattle, he and his followers began introducing
these living tubercle bacilli into the bodies of infants and
children. In the human body it is impossible to deter-
mine the efficaciousness of any immunizing procedure
with such promptness and accuracy as can be done in
animals. Thus theory and speculation are likely to run
rampant and the actual facts are not established until
forty or more years after the veterinarians draw their
final conclusions. Moreover, the period of childhood is
an extremely fruitless age to study the effects of an im-
munizing agent against tuberculosis. This period of life
is notorious for its low incidence of clinical tuberculosis,
with the exception of the first year or so when acute re-
infection forms, such as meningitis, pneumonia and
miliary disease, cause considerable destruction wherever
there is a great deal of exposure to adults who have con-
tagious disease.

Since 1922 more than two million children, as well as
some adults, have had BCG administered. This tran-
spired mostly in Europe, Africa and Asia, and only to
a small degree in the western hemisphere. To date the
reports have been extremely confusing. Some of them
have shown encouraging results, while others have pre- [
sented nothing to show any benefit whatsoever resulting
from BCG. It has been disheartening to find that in
every sizeable group vaccinated with BCG there has been
illness and death from tuberculosis. More depressing
than this, however, is the fact that of all the studies
that have been conducted in different parts of the world
to date, not one has been adequately controlled. Any
benefit that might appear to have occurred among those
vaccinated can usually be explained on the basis of such j
factors as protection against exposure to contagious cases,
while the controls were not so protected.

If BCG were as efficacious in controlling tuberculosis '
among humans as all physicians would desire it to be,
certainly nearly a quarter of a century of trial would not
have left the medical profession in a state of confusion.
Probably the two most carefully conducted studies on
BCG have been carried out in the United States, one
in New York and the other among Indians. These
studies were reported in national journals in June 1946,
and the results are almost diametrically opposed. For
example, the observations among Indians are somewhat
favorable; whereas, in the New York study there was
no significant difference in the subsequent development

July, 1946

239

of tuberculosis among the vaccinated and the unvac-
cinated.

Of the large number of reports on BCG among hu-
mans since 1922, the most that can be said of any is
that it is slightly encouraging. There is not a single
report in the literature of the world that has demonstrat-
ed its efficacy in an overwhelming manner. There is not
a community or a political division in the world having
used BCG, that can show accomplishments which in any
sense of the word approach those in large areas of the
United States where fundamental control procedures
have been practiced.

Probably few persons would object to further experi-
ments with BCG in small human groups where tubercu-
losis is rife and fundamental control measures are not
possible. However, to advocate its universal use at this
time would be to experiment on our public, to confuse
our workers, and delay the ultimate control of the dis-
ease by at least half a century. J. A. M.

SOUTH DAKOTA FORGES AHEAD

Donald Horace Slaughter, M.D., has been selected
and has accepted the appointment as Dean of the School
of Medicine in the University of South Dakota at Ver-
million. Doctor Slaughter has an excellent record, not
only as a teacher and research worker but as an outstand-
ing administrator. He was born in 1905, graduated from
the State University of Iowa College of Medicine in
1929 and has occupied important teaching and adminis-
trative positions since then in Baylor University College
of Medicine, later Dean of Students, Southwestern Med-
ical College, Dallas, Texas. He was secured for South
Dakota and accepted by the President and the Board of
Regents largely through the efforts of J. C. Ohlmacher,
M.D., the retiring dean, who has known Doctor Slaugh-
ter over a period of years and has watched the growth
of his career throughout that time with intimate interest
and is convinced that Doctor Slaughter is just the type
of man that is needed to develop a good four-year med-
ical school in South Dakota. For his part, Doctor
Slaughter is well aware of the difficulties which he will
encounter in this development, but is willing to accept
the challenge because he is thoroughly "sold” on the
belief that South Dakota needs and can have a good
four-year school.

Doctor Ohlmacher will remain as head of the depart-
ment of pathology, Director of the S;ate Health Lab-
oratory and Dean Emeritus. He will continue as head
of the department of pathology until he is assured that
it will be turned over to competent hands and shall have
reached that stage of development which he considers
essential. His attitude toward the new arrangement is
well set forth in the statement which he made to Gov-
ernor Sharpe and the Board of Regents at the time
President Weeks and he talked to the group on the need
for the development of a four-year school. As part of
the general written statement which he made at that
time Doctor Ohlmacher included the following:

"It is suggested that at the earliest opportunity, the
services of a comparatively young, vigorous, well-trained
medical dean be procured to assist in the organization

of clinical instruction, including the development of an
adequate faculty. I shall continue to do all I can toward
the consummation of our objective, the development of
an accreditable four-year school, but the many activities
and responsibilities which have been imposed on me,
my age, and other factors dictate the necessity of inject-
ing new blood into the administration of the School’s
affairs in this critical period of its development, and of
relieving me of considerable of the responsibility I am
now carrying. I shall continue to do all I can for the
School so long as health permits and so long as I may
be permitted to remain identified with its interests and
the interests of the University of which it forms a part.”
The advantages of the arrangement just outlined are
too obvious to justify extended discussion. Not only will
the School be benefited by the addition of the appoint-
ment but all the valuable experience and intimate knowl-
edge which have accrued through the years of Doctor
Ohlmacher’s connection will be retained. The outlook
for the success of the school is most promising.

G. C.

Views Items

NEWS FROM SOUTH DAKOTA

The 65th Annual Session of the South Dakota State
Medical Association was held in Aberdeen, June 1-4.
This being the first postwar meeting, it was dedicated
to the physicians of South Dakota who served in the
Armed Forces. Authorization was made for a committee
on prepaid medical care to draw up a plan of voluntary
health insurance subject to the approval of the council-
lors and the membership. Also authorized was the adop-
tion of a plan whereby veterans with service disabilities
can obtain medical care from private physicians at gov-
ernment expense. Other states in this region which have
adopted the plan include Minnesota, Michigan, and
Iowa.

Redfield was selected as the site for next year’s con-
vention. Newly elected officers and councillors are:
Dr. F. S. Howe, Deadwood, president; Dr. H. R.
Brown, Watertown, president-elect; Dr. J. L. Calene,
Aberdeen, vice president; Dr. R. G. Mayer, Aberdeen,
secretary-treasurer. Dr. C. E. Robbin, Pierre, was re-
named chairman of the council. Councillors elected are:
Dr. A. W. Spiry, Mobridge, 11th district; Dr. R.
Quinn, Burke, 10th, and re-elected; Dr. R. E. Jem-
strom, Rapid City, 9th district, and Dr. D. A. Gregory,
Milbank, 12th.

Sunday’s meeting heard reports of more than 200
committees, and addresses by Dr. E. C. Andreassen,
assistant medical director of the Veterans Administra-
tion of Minneapolis, Dr. W. Duncan, Webster, Dr.
F. S. Howe, Deadwood, and Dr. F. E. Clough, formerly
of Mitchell, now practicing in San Bernardino, California.

The following scientific program was presented on
Monday: "Office Practice of Gynecology,” Dr. L. Lang,
Minneapolis, clinical assistant professor of obstetrics and
gynecology at the University of Minnesota; "Complica-

240

The Journal Lancet

tions in Bilateral Congenital Polycystic Disease of the
Kidney,’ Dr. T. P. Grauer, Chicago, associate professor
of urology, Northwestern University; "Importance of
Some Remedial Aspects of Heart Disease,” Dr. N. C.
Gilbert, Chicago, professor of medicine, Northwestern
University; 'Pathology of the Retinopathy of Chronic
Glomerulonephritis and Hypertension,” Dr. W. Camp,
assistant professor of ophthalmology, University of Min-
nesota; "Acute Cholecystitis,” Dr. A. Ochsner, New
Orleans, director of the department of surgery, Tulane
University; "Bulbar Type Acute Poliomyelitis — Diag-
nosis and Treatment,” Dr. J. H. Murphy, FAAP,
Omaha, associate professor of pediatrics, Creighton Uni-
versity; "Clinical Aspects of Chemotherapy,” Dr. W. H.
Hall, clinical instructor in medicine at the University of
Minnesota; "A Report on the Activities of the Council,”
Dr. A. W. Adson, Mayo Clinic, member of the council
on Medical Service and Public Relations.

Tuesday’s scientific program consisted of the follow-
ing addresses: "Surgical Considerations,” Dr. A. Ochs-
ner, New Orleans; "Gross and Microscopic Pathology,”
Dr. J. R. McDonald, head of the surgical pathology
section of the Mayo Clinic; "Therapeutic Radiology,”
Dr. H. H. Browning of the therapeutic radiology sec-
tion of Mayo Clinic; "Purpose and Methods of the
American Cancer Society,” Dr. A. W. Oughterson, New
York, piedical and scientific director of the American
Cancer Society; Public Health and Organized Medi-
cine, Dr. A. B. Price, Kansas City, senior surgeon,
USPHS district office; "Psychosomatic Medicine,” Dr.
G. R. Kamman, St. Paul, assistant clinical professor of
nervous and mental diseases, University of Minnesota;
"Modern Concepts of Hypertension,” Dr. K. G. Kohl-
staedt, Indianapolis, director of Lilly Laboratory for Clin-
ical Research, Indianapolis City Hospital; "Management
of Breech Delivery,” Dr. L. A. Lang, Minneapolis.
X-ray films were discussed by Dr. N. J. Nessa of Sioux
Falls, and Dr. P. V. McCarthy of Aberdeen.

The Woman’s Auxiliary to the South Dakota State
Medical Association held their annual state meeting in
Aberdeen, June 1-4. Dr. G. Cottam, Pierre, Superin-
tendent of the State Board of Health, spoke on the
Wagner-Murray-Dingell Bill.

Doctors from surrounding territories are invited to
participate in the ward rounds which are made every
Saturday at 9 A.M. at Sioux Valley Hospital, Sioux
Falls, and at 10 A.M. at McKennan Hospital, Sioux
Falls.

NEWS FROM MONTANA

Dr. J. L. Mondloch of Butte was reappointed Silver
Bow county physician and secretary of the board of
health for the fiscal year 1946-47, at a special meeting
of the board of county commissioners on May 24.

Dr. Charles P. Brooke, who served four years with
the army medical corps, both in this country and over-
seas, has taken over the practice of Dr. George Armour,
for twenty-three years resident physician in St. Ignatius.

NEWS FROM NORTH DAKOTA

The North Dakota Academy of Ophthalmology and
Otolaryngology held its annual meeting at Bismarck,
May 28. Dr. H. L. Bair of Rochester, Minnesota, ad-
dressed the society on "Newer Therapeutic Measures in
Ophthalmology,” and Dr. M. T. Lampert of Minot,
North Dakota, on ' Glaucoma, its Mechanism.”

The following officers were elected: Dr. E. D. Perrin
of Bismarck, president; Dr. H. L. Reichert of Dickin-
son, vice president, and Dr. M. T. Lampert of Minot,
secretary for the year 1946-47.

The next meeting will be held in Minot.

DEATHS

Dr. Norman E. Anderson, 65, of Harmony, Minne-
sota, died June 12 from a heart attack. Dr. Anderson,
who had practiced for 40 years at Harmony, was born
at LaCrosse, Wisconsin, March 16, 1881.

CUuttifUd Aduc*ti*e*HC*U«

LOCATION FOR PHYSICIAN

Armour, good county seat town in prosperous com-
munity in southeastern South Dakota. No physician in
entire county. Good office quarters, which have pre-
viously been occupied by a physician, are available for
immediate occupancy. Address reply to J. A. Liddiard,
Sec. Armour Commercial Club, Armour, South Dakota.

ASSISTANT WANTED

Wanted by well established surgeon in suburb of Twin
Cities, an assistant interested in general practice and in-
ternal medicine. Excellent opportunity for an adaptable
individual. Address Box 843, care of this office.

PRACTICE FOR SALE

Active general practice in town of 550 north central
Minnesota, with house-office combination completely mod-
ern, grossing #15,000.00 yearly. Excellent hospital facili-
ties nearby. Prefer sale house-office cash or terms. Pur-
chase of drugs and equipment optional. Address Box
83 3, care of this office.

PHYSICIAN AND SURGEON WANTED

X-RAY PRACTICE

FOR SALE

Used equipment in excellent condition, consisting of
portable X-ray unit with dark room equipment, Castle
sterdizer, automatic thermostatic and humidity control
infant incubator, operating table, instrument cabinet and
table, metal basin and intravenous stand, and suction
pressure portable tonsil machine. For information please
contact Dr. R. A. Benke, Kalispell, Montana.

bribe,

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NEW YORK 17

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Aznoe’s, established in 1896, has available a number
of well trained physicians (diplomates of the specialty
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SEELERT CELEBRATES SILVER JUBILEE

The Seelert Orthopedic Appliance Company is celebrating its
25th year of business this month. They have recently moved
their offices and salesroom to 18 North 8th Street, where larger
and more modern quarters are available. Mr. Seelert announced
that the firm intends to resume the manufacture of artificial
limbs, with plans for production to start about July 15th.

ALADDIN HEARING AID

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find difficulty in wearing ordi-
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Samples and literature on request.

DOAK C0..INC.

CLEVELAND* OHIO

IN THE VOMITING OF PREGNANCY

or that occurring as a re-
sult of a neurosis or re-
flexly from relapsed kidney
or uterine misplacement

FhSADYME

will be found highly effi-
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marked sedative powers.

Reflex phenomena are a
definite indication for

PASADYNE.

JOHN B. DANIEL. INC.

ATLANTA. GA.

Spontaneous Rupture of a Hydronephrotic Kidney

Report of a Case

Roland G. Scherer, M.D., F.A.C.S.*

Bozeman, Montana
and

John K. Odegard, M.D.f
San Francisco, California

In reviewing the literature on renal injuries, one is im-
pressed by the exceedingly rare occurrence of such
injuries presented as emergencies. Lazarus found an
incidence of 0.05-0.09 per cent of renal injuries of all
types, basing his figures on 45,500 admissions to the
surgical divisions of three great clinics. Stirling believes
"The relative occurrence of all kidney trauma is ap-
proximately one in one thousand accidents.”

It thus becomes evident that any renal injury arising
from no attributable trauma, direct or indirect, is ex-
tremely rare.

The term "spontaneous rupture” is perhaps a mislead-
ing one because in no instance of the cases reviewed is the
spontaneity definitely established. "Spontaneous rupture”
per se should occur at a moment of absolute rest and
in an otherwise normal kidney. In all the cases reviewed
the rupture occurred during periods of relative inactivity,
but in every instance the kidney involved was found to
be diseased. The diseases involved were many and varied
and included tuberculosis, abscess, tumor, necrosis of
the suprarenal, hemophilia, chronic nephritis, hydro-
nephrosis, infarct, renal arteriosclerosis, with cystic de-
generation, and periarteritis nodosa.

Of most importance and particularly applicable to
those cases of spontaneous rupture occurring in the sec-
ond and third decades is hydronephrosis secondary to

*Consultant in Urology, Fort Harrison Veterans Hospital.
fWritten while in the Army as Major, Acting Chief, Sur-
gical Service, Fort Harrison, Montana.

ureteral obstruction either due to calculus or aberrant
renal vessels as in Henline’s series. In these one may
visualize quite readily a greatly distended, thin walled
kidney which suddenly, and from no apparent cause,
ruptures. The precipitating factor or factors in these
cases may be so obscure and unimportant as to be dis-
regarded or forgotten by the patient. Increased hydraulic
pressure, muscular action and indeed the pressure exerted
on the kidney by merely lying quietly in bed have been
advanced as factors contributing to the rupture. Player
reported a case of rupture which occurred while the
patient was crawling through an open window, the in-
jury being caused by simply rolling over the window
ledge.

The diagnosis of these injuries which do not involve
the parenchyma or large vessels is exceedingly difficult.
It is quite apparent that rupture of the kidney pelvis
may occur proximal to an obstruction in the ureter which
will result in the escape of urine but no blood or at best
with only intermittent bleeding. These may go on to
form large peri-nephric abscesses with extravasation of
urine in the supra-pubic region, scrotum and perineum
as reported by Henline. Kretschmer states that "a his-
tory of injury, no matter how slight, and the presence
of blood in the urine, would seem to be prima facie
evidence of direct kidney damage.” Cohn believes that
cystoscopy at the onset is contraindicated but will give
useful information later. Certainly a preliminary "scout”
flat film of the abdomen followed by excretory pyelog-

241

242

The Journal Lancet

raphy are invaluable aids to diagnosis. The decision as
to whether to use cystoscopy may well be left to the
judgment of the surgeon. Its use is indicated in border-
line cases to determine the function of both the involved
and uninvolved kidneys.

Conservatism is the treatment of choice and will suf-
fice in approximately 90 per cent of kidney injuries.
Expectantly one gives purely supportive care consisting
of fluids by mouth or vein, sedation, narcotics to relieve
pain and absolute bed rest until the urine is free of
blood. One is impressed by the fact as pointed out by
Cohn that a severely injured kidney left in situ will un-
dergo atrophy and calcification. Mucharinskij, in his
experiment on dogs, found that not only did such atro-
phy and calcification occur, but that in over one half
of his animals interstitial changes were observed in the
uninjured kidney commencing with the third week.

Cohn believes that the indication for early operation
is "severe uncontrollable primary or early secondary hem-
orrhage, extravasation of urine, or symptoms of peri-
tonitis due to injury of the peritoneum with the escape
of blood and urine into the abdominal cavity.” Secon-
dary hemorrhage, suppuration in the perirenal space and
infection of the kidney are later indications for surgery
according to Kretschmer.

The following case is presented because of its appar-
ent spontaneity and because it represents one of those
cases which demanded immediate surgical intervention
as a lifesaving measure.

L. G., white, aged 23, ex-serviceman employed as la-
borer by the Highway Commission, was admitted to the
surgical service late on January 8, 1946, via ambulance
from an outlying community. He had been in excellent
health until midnight, January 5, at which time he began
to have a slight pain in his left flank shortly after retir-
ing. The pain was persistent and of a dull aching char-
acter which gradually increased in intensity, radiating
forward and down toward the bladder region and the
middle of the abdomen. On January 6 he noticed that
his urine was "coffee colored.” He was seen on Janu-
ary 7 by his family physician who made a diagnosis of
"kidney stone” and kept him in bed. However, the pain
persisted and the urine remained "coffee colored.” He
was transferred to the hospital by ambulance late on
January 8.

His health had been excellent and he had suffered no
wound or injuries during his service. Family history was
non-contributory. He gave a history of having had two
similar attacks during his Army service which were of
very short duration (30 minutes to 2 hours) but in
neither attack did he notice any blood in his urine nor
were they of such severity as to require hospitalization.
The last attack prior to the present one was six months
before admission. Nausea or vomiting was not a feature
of the present attack nor of the two previous episodes.
The pain in the left flank was accentuated by move-
ment, coughing, or straining. There was frequency of
urination and some tendency to polyuria. There was no
history of injury past or present. Pain in left flank and
bloody urine were the complaints on admission.

Physical examination: Height 5 feet 11 inches; weight
165 pounds; eyes blue; hair dark brown. Blood pressure
122/70, temperature 100, pulse rate 92. The patient was
a very well developed, well nourished, 23-year-old white
male who appeared acutely ill and complained of severe
pain in his left flank which appeared to be persistent.
EENT — negative except for excessive dryness of lips
and mucous membranes of the tongue and mouth.
Chest — clear to auscultation and percussion. Heart —
negative. Abdomen — symmetrical. Slight to moderate
distention which appeared to be diffuse. There was an
area of erythema on the left flank secondary to the use
of a hot water bottle before his admission. There ap-
peared to be some fulness in the left flank which was
acutely tender to palpation. Abdomen was soft with no
rigidity or guarding. There was no evidence of trauma.
Hernia — none. Hydrocele or varicocele — none. Extremi-
ties— negative.

He was placed in a semi-Fowler’s position, fluids in the
form of 10 per cent dextrose in distilled water were
given intravenously and pain controlled by narcotics. He
was immediately typed and transfused twice before op-
eration, once during surgery and once after operation.

The urine was a deep claret color grossly. Reaction —
acid. Specific gravity — 1.028. Albumin — 4 plus, sugar —
negative, mucus, casts, epithelia, cylindroids — none.
W.B.C. — few, R.B.C. — packed. Blood count on admis-
sion: R.B.C. — 3,940,000; W.B.C. — 27,450 (polymorpho-
nuclear— 93 per cent [4 stabs], lymphocytes — 7 per
cent). Hemoglobin — 13.3 grams (88.6 per cent); color
index — 1.13; sedimentation rate — 25; bleeding time —
2 minutes 45 seconds; coagulation time — 6 minutes.
Blood urea nitrogen — 13.08.

X-ray examination of the chest revealed no deviation
from the normal in the pulmonary or cardiac shadows.
A flat plate of the abdomen revealed the large intestine
and a portion of the distal small intestine to be markedly
distended with gas which was not significant of obstruc-
tion. Detail was obscured in both kidney areas but the
right psoas muscle was well outlined and the left not
demonstrable. On the left there was an increase in soft
tissue density over the kidney area. No opacities sug-
gesting urinary lithiasis were noted right or left. Ex-
cretory pyelography revealed good function on the right
and practically no function on the left. In the left kid-
ney area large markedly dilated calices were faintly out-
lined in a large faintly visible kidney mass. Neither
pelvis nor ureter on the left was visualized. Bladder
shadow appeared normal.

The patient was seen inconsultation at 6 p.m., Jan-
uary 9, at which time it was noted that the dullness in
the left flank did not shift when the patient was turned
on his right side, indicating definitely an extraperitoneal
mass. Cystoscopy was believed contraindicated by the
patient’s condition. In view of the apparent uncontrol-
lable hemorrhage manifested by a rapidly increasing
pulse rate, a decreased red blood count in spite of two
transfusions, each of 500 citrated blood, the administra-
tion of fluids, and the good function of the right kidney,
it was felt that immediate surgery, most probably neph-
rectomy, was imperative. Preoperative diagnosis: Rup-

August, 1946

243

tured kidney with severe hemorrhage; probably a mul-
tilocular non-functioning kidney.

Under spinal anesthesia a classical left lumbar incision
was made. The thin perirenal capsule of Gerota was
distended with organized hematoma. On exposure the
kidney capsule had a dark hemorrhagic color and was
markedly distended, the kidney being approximately four
times the size of a normal kidney. Active bleeding from
the kidney was encountered. As it was impossible to
determine the source of this bleeding, and as the cortex
of the kidney felt very thin, nephrectomy was decided
upon. Because of a short pedicle, the kidney could not
be delivered into the wound. Two large clamps were
therefore placed on the pedicle of the kidney superiorly
and inferiorly and the organ removed. The ureter was
ligated and bleeding controlled. The pedicle was ligated
with chromic catgut and a portion of the large redun-
dant pelvis, which had been cut across, was removed. The
wound was closed in layers over a Penrose drain. Im-
mediate postoperative condition was excellent, the patient
having received intravenous fluids and transfusion of
whole blood during the operation.

The patient made an uneventful recovery and three
months later had gained ten pounds over his initial
admission weight. The wound was well healed with no
evidence of hernia and the urine was negative.

Pathological description: "Specimen submitted meas-
ures approximately 15x9x9 cm. Immediately postopera-
tively it is collapsed but apparently had been distended
with bloody fluid. Careful examination of the pelvis and
upper ureter reveals no calcification which would account
for the marked dilatation of the pelvis. The dilatation
ceases abruptly at the ureteropelvic junction in a manner
suggesting the presence, in vivo, of an aberrant vessel
as the obstructing agent. The capsule is hemorrhagic
in appearance. The cortex and medullary substance are
markedly thin, measuring approximately .5 cm. The
calices, infundibula and pelves are markedly distended
and have the appearance of diverticuli. The mucosa is
partly smooth and partly covered with small hemorrhagic
nodules. Hemorrhage is apparent beneath the mucosa

and in the kidney substance. The hemorrhage appears
to have origin in an area just beneath the mucosa proxi-
mal to one of the enlarged calices. It would appear that
a rent through the mucosa and into the submucosal renal
parenchyma avulsed and ruptured a renal vein. The eti-
ology of the rent is probably an acute exacerbation of the
hydronephrotic obstruction. There is no evidence of neo-
plasm and no marked evidence of inflammation. There
is no interruption of the capsule of the kidney and no
external findings which would suggest trauma.”

During the patient’s hospital stay, a further attempt
was made to discover a history of injury however remote
but he was unable to recall having suffered any either
during service or as a civilian.

Summary

1. A case is presented of spontaneous rupture of a
hydronephrosis secondary to ureteral obstruction, most
probably due to an aberrant renal vessel.

2. Rupture occurred while patient was lying quietly
in bed and resulted in uncontrollable hemorrhage.

3. Diagnosis was made by examination, excretory py-
elography and confirmed at operation and pathological
examination of the specimen.

4. Excretory pyelography was especially useful in diag-
nosis and also in determining the function of the un-
involved kidney.

5. Early recognition and immediate nephrectomy was
life-saving in this case.

Bibliography

Amberger: Spontaneous Rupture of Right Kidney. Ztschr.
f. Urol., Berl. & Leipz., 20: 561-63, 1926; Abs.: J.A.M.A.,
87: 1251, 1926.

Beatty, Ralph P.: Hydronephrosis — Spontaneous Rupture.

Pennsylvania Med. Journal, 38: 806-7, 1935.

Cohn, Sidney: Subcutaneous Injury of the Kidney. Internat.
J. Med. & Surg., 40: 318-20, 1927.

Connell, F. Gregory: Simple Subparietal Rupture of the

Kidney. Surg., Gynec. & Obst., 663-666, (June) 1916.

Dodge, George E.: Subcutaneous Rupture of the Kidney.

Floyd, E., and Pittman, J. L.: Spontaneous Rupture of a

Kidney Due to an Encysted Calculus; Report of a Case.
J.A.M.A., 97: 98, 99, (July) 1931.

Freshman, E.: Extravasation of Urine Following Spontaneous
Rupture of the Ureteropelvic Junction. Brit. J. Urol., 267-70,
(Sept.) 1935.

Henline, R. B.: Spontaneous Rupture of a Kidney; Report
of a Case. J.A.M.A., 83: 141 1-14, (Nov.) 1924.

Keefer, Chester S.: Spontaneous Perirenal Hematoma. J. Mt.
Sinai Hosp., 8: 682-691, (Jan. -Feb.) 1942.

Larks, George: Spontaneous Rupture of a Hydronephrosis.
Brit. J. Surg., 29: 354-356, (Jan.) 1942.

Lazarus, J. A.: Subcutaneous Rupture of a Kidney with Spe-
cial Reference to Spontaneous Rupture. Urol. & Cutan. Rev.,
38: 77-84, (Feb.) 1934.

Mathe, C. P., and Oviedo, G. F.: Spontaneous Rupture of
Hydronephrotic Sac Secondary to Ureteral Stone. Calif. &
West. Med., 26: 790-795 (June) 1927.

Olson, Carl: Spontaneous Hydronephrosis in the Dog, with
Osteoid Tissue in the Renal Pelvis. J. Amer. Veterinary M.A.,
87: 74-80, (July) 1935.

Reschke, K.: Rupture of Kidney in Hydronephrosis, Deutsche
Ztschr. f. Chir., Leipz., 185: 137-142; Abs. J A M A., 82:2092,
1924.

Salvin, Arthur A.: Spontaneous Rupture of a Hydroneph-
rotic Kidney Secondary to Calculus Obstruction of Ureter. Am.
J. Surg., 41:288-292, (Aug.) 1938.

Truesdale, Philemon E.: Injury to the Kidney Without an
Open Wound. Boston M. & Surg., (March 17) 1927.

244

The Journal Lancet

Serology and Obstetrics II

R. T. La Vake, M.D.

Minneapolis, Minnesota

Obstetricians who have come to insist upon a rou-
tine knowledge of the blood group and Rh status
of husband and wife, as well as the Wassermann status,
have not been activated by an exaggerated idea of the
frequency with which the findings will play an impor-
tant role. These findings may all be obtained from the
one drawing of blood and engender a feeling of rea-
soned security or preparedness. This routine permits the
building up of potential sources of Rh negative blood
of every group, which can be used in case of need, in
the interests of mother or child.

From an obstetrical standpoint, the patterns of indi-
vidual blood findings would seem to be the evolutionary
genetic results, in whatever inscrutable developmental
direction the species is moving, which furnish a mother
with a complement of inherited antitoxic substances
against the eventuality that she may, according to laws
enunciated by Mendel, engender a child containing an-
cestral substances poisonous to her. When such an
eventuality occurs, a toxin antitoxin battle ensues between
fetus and mother. The outcome depends upon the rela-
tive toxicity of the fetal substance, whether it can gain
access to the maternal blood stream through a faulty
protective placental barrier in sufficient quantities to do
harm, whether the mother is sufficiently protected by
inherited antitoxic substances, and, if not, the capacity
of her cells to manufacture specific antitoxins. If the
mother responds with too strong an antitoxin, the child
may be injured or killed.

This is a reason why the O group mother is endowed
wit hthe A and B antitoxins, the A group mother with
the B antitoxin, and the B group mother with the A
antitoxin. To the AB group mother neither the A or
the B substance is toxic because she possesses them by
inheritance. The Rh negative mother is not protected
by inherited antitoxins. An explanation of this fact,
drawn from the findings of ontogeny, is that the Rh
substance likely entered the species early enough to be-
come inheritable, but too recently for its specific anti-
toxin to become inheritable. According to Kemp, the
A and B substance become demonstrable in the fetus
about the 37th day of gestation, yet the fetus’ own
complement of inherited antibodies or antitoxins does
not appear until after birth. From an ontogenic stand-
point it would seem that it takes about eight times
longer for an intraspecies antitoxin to become inheritable
than for a substance or toxin to become inheritable.
In considering blood setups, we must remember that we
are viewing only an infinitesimal segment in the whole
evolutionary line of the species. Many substances may
have been bred in and out of the species before the

*This is a follow-up of an article by the same author under
the same title in the January 1946 Journal-Lancet.

Read at the May 4, 1946, meeting of the Minnesota Society
of Obstetrics and Gynecology, Minneapolis, Minnesota.

advent of the A and B and the Rh substances, and from
irregular agglutination phenomena today, it is likely that
we have not yet reached the limit of the possible sub-
stances that now exist, with or without their specific
inherited antitoxins.

If, by analyzing the blood setups of husband and wife,
one can be quite certain from genetic laws that the child
cannot inherit a substance toxic to the mother, one can
likewise be quite sure that pregnancy toxemia with asso-
ciated anemias, premature separation of the normally im-
planted placenta, or any fetal pathology attributable to
toxin antitoxin reaction will not be encountered. Also the
chances of spontaneous abortion are much reduced, even
in the presence of severe general infection in the mother.
This knowledge is helpful in many ways, especially in
differential diagnosis. When this ideal setup does not
occur, it is possible to estimate the chances that the in-
fant may inherit the mother’s blood setup.

Whether or not any manifestations of toxemia occur,
the titering of antibodies will allow one to predict, with
fair accuracy, the blood status of the child. The predic-
tion depends on the appearance or increase of Rh anti-
body titer as regards the Rh substance, and as regards the
A and B substances, a significant rise above normal limits
of the specific inherited antibody. For example, in an
O mother, with an A husband, and the accession of tox-
emia, such a rise will be found in the A antibody or
antitoxin, and the child will prove to be an A group
child. Should the A antitoxin titer remain around 1-1000
until the child is born, with the mother evincing mani-
festations of mounting toxemia, then the rapidity of the
recession of the manifestations will vary directly with
the rise in the antitoxin titer in the mother at the birth
of the child. Separation of the child and placenta has
brought about a lowering of toxic insult, and has with-
drawn the antitoxin absorptive power of the child. In
consequence, the antitoxin accumulates and rises in titer.
It is best to take the postpartum titer on the fifth day
when it is likely to be at its peak. The antitoxin titer
may rise from a few to one hundred or many hundred
times its antepartum strength, with a rapidity of reces-
sion of toxic manifestations proportional to its rise.

Such findings make us hark back to the clinical work
of James Young in 1914 when he stressed the necessity of
removing all placental detritus after delivery in toxemics.
The toxin antitoxin findings explain the basis of the clin-
ical observations that led to attributing pregnancy tox-
emia to placental changes. Obviously, the placenta is the
firing line of the toxin antitoxin battle and should show
some outstanding results.

Since the time of Veit, in 1902, it has been known
that villi can break off. If this occurs, the suggestion
that a blood spill may occur is logical. These breaks, or
even weaknesses, allowing direct antibody . attack are
likely sealed by what are designated as placental infarcts.

August, 1946

245

Clinical evidence would suggest that these infarcts can
operate to the advantage or disadvantage of fetus and
mother, according to the time elapsing between their
formation and the spontaneous or operative separation
of the child from the mother.

These findings give ample evidence of the reasons for
success in the past following the separation of the fetus
from the mother before permanent or lethal damage was
sustained by the mother or the child.

By developing antitoxin in a convenient form we
should have at our command at least three specific anti-
toxins to use in postpartum eclampsia or in the mitiga-
tion of further toxic insult after the birth of the child.
The exact type of antitoxin necessary can be determined
and sought long before its use is required, in most in-
stances. At present, we would be limited to the use of
compatible blood from a woman who has just recovered
from the same type of pregnancy toxemia or erythro-
blastotic disaster, and whose antibody is of high titer.

If one is following an antibody titer, he may see the
titer with the accession of a maternal infection jump to
many times its preinfection level and remain at this
higher level until the infection is over. These findings
would tend to corroborate the stand, based upon clinical
observations alone, that it is wise, from a prophylactic
standpoint, to clear up focal infections, such as pyelitis,
etc., and caution pregnant women against general infec-
tions. Should infection occur, the physician must vis-
ualize the increased likelihood of gross infarction with
the increased tendency towards abortion or death of the
fetus and the accession of toxemia when the infarcts
begin to hemolyze. When infection exists, it lessens one’s
anxiety to know that the expectant mother is carrying a
fetus which should not be toxic to her according to sero-
logic data.

As regards the use of blood therapeutically, by trans-
fusion and even by intramuscular injection, it is quite
true that before the discovery of the Rh factor by Land-
steiner and Wiener, we achieved safety in transfusion by
the use of careful grouping and crossmatching, especially
the latter. The major consideration is ascertaining that
the recipient’s blood contains no antibodies, known or
unknown, which will agglutinate the cells of the donor.
The work of Wiener and Peters, and others, showing the
possibility of iso-immunization and subsequent danger of
repeated transfusion with the blood of the original donor,
and the danger of iso-immunization from pregnancy and
its possible effects on the fetus shown by Levine, Katzin,
and Burnham, have increased our responsibilities as re-
gards giving transfusions to women.

If a woman is pregnant, or gives a history of having
had either a pregnancy or a transfusion, one must con-
sider the Rh setup in her blood, and exercise special care
in crossmatching before transfusion. In addition one
must recognize the risk of iso-immunizing an Rh nega-
tive woman by giving her Rh positive blood. After iso-
immunization, she may never be able to bear healthy or
viable children by the same, or any other Rh positive
male unless he bears heterozygous Rh genes that permit
her having an Rh negative child. There is no intention
of exaggerating the chances that iso-immunization will

result, or the possibility that the woman’s chances of
bearing healthy and viable children will be ruined. But,
if one has had any experience with erythroblastotic or
kindred disasters, he will take his responsibilities, in re-
gard to the Rh factor and transfusion, seriously. The
use of transfusion has increased, and, in the interests of
diminished morbidity and mortality, its use has not
reached the saturation point. But when one sees the Rh
factor disregarded in females below the age of meno-
pause, one cannot but fear a marked increase in erythro-
blastotic and kindred disasters. It is well to emphasize
that our serologists have found that transfusion is ten
times more likely to iso-immunize a woman than is a
pregnancy.

Serologic data in obstetrics would seem to indicate that
we should look upon a blood containing the A, B, or Rh
substance or substances not inherited by the recipient as
basically toxic. Toxic action is most clearly demonstrable
in pregnancy toxemia, where it has had a long time to
develop and is not obscured by red cell agglutination and
red cell detritus, and also in some cases of delayed trans-
fusion deaths. In rapid transfusion deaths, the toxic
effect has not been given time to make itself evident or
is totally obscured by red cell agglutination and red cell
detritus.

This viewpoint, if correct, would make it seem advis-
able to use nontoxic blood in transfusing infants in the
early months of life. The statement is made that any
type blood can be used because the danger of agglutina-
tion is absent due to weak antibodies. The same has been
said also of the intramuscular injection of blood where
the danger of agglutination can be avoided. However,
definite pathological reactions have been reported follow-
ing the intramuscular injection of blood. It would seem
likely that such phenomena are due to a toxin and not
to any agglutinative phenomena.

The attempt has been made to outline the practical
as well as the theoretical inferences and conclusions that
have been drawn from data as they appear from one
viewpoint. These data must withstand the test of cor-
roboration which only time and extensive investigation
can furnish. If individual conditions of practice are such
that the use of serology is impossible, the following sug-
gestion may be useful: just as one can usually recognize
the beginning of pregnancy toxemia by the simple office
observation of blood pressure, urine, edema and weight,
so one can usually anticipate the possibility of future
serious erythroblastotic injury by the routine hemoglobin
estimation of newborns. A child with a hemoglobin of
100 or under should be watched carefully and placed
in an environment where transfusion is possible. Its par-
ents should have their group and Rh status determined
before another pregnancy occurs. As all know, erythro-
blastotic disaster does not always occur in the first few
pregnancies. In one case, a mother bore seven healthy
children, followed by erythroblastotic deaths in the
eighth and ninth pregnancies. In another, on the other
hand, the first two pregnancies resulted in erythroblas-
totic disasters.

Granted that one knows the group and Rh status of
husband and wife and is prepared to test for the acces-

246

The Journal Lancet

sion or rising strength of antibodies, it seems to be the
consensus that it is not expedient to interfere until after
the first fetal disaster. Even if a woman does show a
mounting titer she may deliver a child that shows no
sign of injury or can be saved by transfusion, but which
might die from immaturity if separated prematurely.
If after one disaster, or a history of a previous erythro-

. . . dlEET OUR (MRIBUTORS . . .

Dr. Roland G. Scherer, Bozeman, Montana, has
practiced there since 1936. He is a graduate of the Uni-
versity of Minnesota, M.B., 1926, M.D., 1927, and was
a Fellow of the Mayo Foundation from 1931 to 1935.
His specialty is Urology. He is Chief of Surgery at the
Bozeman Deaconess Hospital, consultant in Urology at
the Fort Harrison Veterans Hospital, and a member of
the Gallatin County Medical Society, Montana State
Medical Association, American Medical Association,
North Central Urological Association, and a Fellow of
the American College of Surgeons.

Dr. Rae Thornton La Vake, well-known Minne-
apolis obstetrician, is a frequent and valued contributor
to Journal Lancet.

BmU Reviews

Home Study Course in Social Hygiene Guidance. Six
chapters by Roy E. Dickerson, and nine pamphlets by Dr.
Paul Popenoe. Los Angeles: American Institute of Family
Relations, 1944. $2.00.

This course consists of six booklets prepared for the Ameri-
can Institute of Family Relations by Roy E. Dickerson and
nine pamphlets by Dr. Paul Popenoe. The course is intended
primarily for parents but would be helpful to teachers and doc-
tors, in fact anyone interested in the education and guidance of
children and youth. The six lessons are: (1) Parental prepa-

ration for training the child; (2) The questions children ask
or do not ask; (3) Preparing the child for adolescence; (4)
Emotional health in adolescence; (5) Some problems in ado-
lescence; (6) Looking ahead to marriage. Helpful suggestions
are given about additional books and pamphlets for those read-
ers who desire a fuller treatment of various topics.

Throughout the course Dr. Dickerson emphasizes the parents’
responsibility in the education of children and the importance
of guidance being based on true, scientific facts and sound,
wholesome attitudes. Both Popenoe and Dickerson repeatedly
emphasize the necessity of any good teacher of children, whether
at home, at school, in church, or in an office, being a happy,
well adjusted, emotionally mature person. Preparation for mar-
riage begins in infancy and continues into marriage itself. Sex
education is not a subject separate and apart but is intimately
tied up with all of life and should be planned within a family
in an intergrated manner. The course not only gives help in
answering specific questions and imparting factual information
concerning sex, but in developing wholesome attitudes toward
human relations in general and sexual relations in particualr.
This excellent series of pamphlets would undoubtedly have
more popular appeal if the print were larger and if more atten-
tion had been paid to eye appeal. But those seeking sound
guidance will not be deterred by such a minor flaw.

K. R.

blastotic disaster, the antibody previously at fault ap-
pears or increases in titer, indicating another toxic fetus,
the consensus directs separate treatment for the child
when it has reached the age of viability. Appropriate
donors should be ready for transfusion treatment. The
chances of success are much reduced if the Rh antibody
is of the blocked variety.

Medical Clinics of North America, Mayo Clinic Number,

July, 1946. Philadelphia: W. B. Saunders Co.

Surgical Clinics of North America, Mayo Clinic Number,

August, 1946. Philadelphia: W. B. Saunders Co.

The contents of these two forthcoming books are listed here
for the information of the many who have been eagerly await-
ing their publication.

The July issue contains: Differential Diagnosis of Spleno-
megaly of Adults, by Dr. Malcolm M. Hargraves; Roentgen
Therapy for Leukemia, by Drs. Walter C. Popp and Charles
H. Watkins; Treatment of Headache, by Drs. Bayard T. Hor-
ton and Dorothy Macy, Jr.; Problem of Blackout and Uncon-
sciousness in Aviators, by Drs. Edward H. Lambert and Earl
H. Wood; Clinical Use of Thiouracil, by Drs. Samuel F.
Haines and F. Raymond Keating, Jr.; Clinical Administration
of Streptomycin, by Drs. H. Corwin Hinshaw and Wallace E.
Herrell; Nonsurgical Management of Bronchiectasis, by Dr.
Arthur M. Olsen; Thiocyanates in Treatment of Hypertensive
Disease, by Dr. Edgar A. Hines, Jr.; Abuse of Sedative Drugs
in Practice of Medicine, by Dr. Frederick P. Moersch; Peni-
cillin in Treatment of Syphilis, by Dr. Paul A. O’Leary; Value
of Gastroscopy in Diagnosis of Gastric Disease, by Dr. Her-
man J. Moersch; Medical Problems in Cases of Acute Ab-
dominal Pain, by Dr. J. M. Stickney; Use of the Newer Sulfo-
namides and Antibiotics in Intestinal Diseases, by Dr. J. Ar-
nold Bargen; Use of Various Kinds of Insulin, by Dr. Randall
G. Sprague; An Appraisal of Radium Therapy, by Dr. Robert
E. Fricke; Chancroid of the Uterine Cervix, by Dr. Lois A.
Day; Habitual Abortion, by Dr. Arthur B. Hunt.

The August issue contains a Symposium on Pain in the
Shoulder and Arm with an introduction by Dr. H. Herman
Young and includes the following articles on the subject: Role
of Thoracic Disease in Production of Arm Pain, by Dr. Arthur
M. Olsen; Arm Pain Due to Heart Disease, by Dr. Harry L.
Smith; Pain in the Upper Extremity Caused by Peripheral Vas-
cular Disease, by Dr. Nelson W. Barker; Neurologic Causes
of Pain in Upper Extremities; with Particular Reference to
Syndromes of Protruded Intervertebral Disk in Cervical Region
and Mechanical Compression of the Brachial Plexus, by Dr.
L. M. Eaton; Orthopedic Aspects of Pain in Shoulder and
Arm, by Dr. H. Herman Young. The remaining section is
entitled Clinics on Other Subjects and includes: Cranioplasty
with Tantalum Plate in Postwar Period, by Dr. George S.
Baker; Problems of Facial Prosthesis, by Dr. Arthur H. Bul-
bulian; Malignant Tumors of the Scalp, by Dr. Frederick A.
Figi; Malignant Lymphocytic Tumors of Orbit, by Drs. Wil-
liam L. Benedict and Theodore G. Martens; Selection of Pa-
tients for Fenestration Operation for Otosclerosis, by Dr. Henry
L. Williams; Skin Grafting Methods and Their Indications, by
Drs. Gordon B. New and Kenneth D. Devine; Some Technical
Aspects of Surgery of Thyroid Gland, by Drs. John dej. Pem-
berton and B. Marden Black; Complications and Treatment of
Bronchial Adenomas, by Drs. O. Theron Clagett and John H.
Payne; Total Gastrectomy: Report of a Patient Surviving for
Eight Years, by Dr. James F. Weir; Resection of the Head of
Pancreas and Duodenum: Operative Technic, by Dr. John M.
Waugh; Total and Subtotal Colectomy with Review of Seventy-
Two Cases, by Dr. Claude F. Dixon and Raymond E. Benson;
Remarks Concerning Malignant Lesions, Polypoid Disease and
Diverticula of Terminal Portion of Large Intestine, by Dr.
Louis A. Buie; Proctologic Diagnosis, by Dr. Newton D.
Smith; Protruded Intervertebral Disk, by Dr. J. Grafton Love;
Further Observations on Treatment of Carcinoma of Prostate
by Bilateral Orchectomy, by Drs. Laurence F. Greene and John
L. Emmett; Indications for Complete Abdominal Hysterectomy,
by Dr. Virgil S. Counseller.

August, 1946

247

Transactions of the South Dakota State Medical

Association

Sixty-Fifth Annual Session
Aberdeen, South Dakota
June

OFFICERS, 1946-47

PRESIDENT

F. S. HOWE, M.D Deadwood

PRESIDENT-ELECT

H. R. BROWN, M.D Watertown

VICE PRESIDENT

J. L. CALENE, M.D. T Aberdeen

SECRETARY-TREASURER

R. G. MAYER, M.D Aberdeen

EXECUTIVE SECRETARY

MR. JOHN C. FOSTER Sioux Falls

DELEGATE TO A. M. A.

WILLIAM DUNCAN, M.D. ....... Webster

ALTERNATE DELEGATE TO A. M. A.

H. R. BROWN, M.D. Watertown

CHAIRMAN COUNCIL

C. E. ROBBINS, M.D. Pierre

COUNCILORS

J. L. CALENE, M.D. (1947) Aberdeen

SECOND DISTRICT

M. W. LARSEN, M.D. (1947) Watertown

THIRD DISTRICT

G. E. WHITSON, M.D. (1948) Madison

FOURTH DISTRICT

C. E. ROBBINS, M.D. (1947) Pierre

FIFTH DISTRICT

W. H. SAXTON, M.D. (1948) ..._ .... Huron

SIXTH DISTRICT

J. H. LLOYD, M.D. (1948) Mitchell

SEVENTH DISTRICT

L. J. PANKOW, M.D. (1948) Sioux Falls

EIGHTH DISTRICT

E. M. STANSBURY, M.D. (1947) Vermillion

NINTH DISTRICT

R. E. JERNSTROM, M.D. (1949) Rapid City

TENTH DISTRICT

R. J. QUINN, M.D. (1949) Burke

ELEVENTH DISTRICT

A. W. SPIRY, M.D. (1949) Mobridge

TWELFTH DISTRICT

D. A. GREGORY, M.D. (1949) Milbank

COUNCILOR AT LARGE

WILLIAM DUNCAN, M.D. (1947) Webster

STANDING COMMITTEES

SCIENTIFIC WORK

F. S. HOWE, M.D Deadwood

H. R. BROWN, M.D Watertown

R. G. MAYER, M.D Aberdeen

PUBLIC POLICY AND LEGISLATION

F. S. HOWE, M.D Deadwood

H. R. BROWN, M.D Watertown

THE COUNCIL

PUBLICATIONS

R. G. MAYER, M.D. Aberdeen

THE COUNCIL

MEDICAL DEFENSE

G. W. MILLS, M.D. (1947) Wall

W. G. RIEB, M.D. (1948) Parkston

c. j. McDonald, m.d. (1949) Sioux Fails

MEDICAL EDUCATION AND HOSPITALS

GEOFFREY COTTAM, M.D. (1947) Sioux Falls

J. L. CALENE, M.D. (1948) Aberdeen

T. F. RIGGS, M.D. (1949) Pierre

1-4, 1946

MEDICAL ECONOMICS

W. A. DAWLEY, M.D. (1947) Rapid City

M. W. LARSEN, M.D. (1948) .... Watertown

M. W. PANGBURN, M.D. (1949) Miller

PUBLIC HEALTH

A. TRIOLO, M.D. (General Chairman) .... Pierre

Sub-committee on Cancer

O. S. RANDALL, M.D. (1948) Watertown

GILBERT COTTAM, M.D. (1947). Pierre

H. E. DAVIDSON, M.D. (1949) .... ... Lead

Sub-committee on T uberculosis

W. L. MEYER, M.D. (1949) Sanator

D. S. BAUGHMAN, M.D. (1948) Madison

E. M. STANSBURY, M.D. (1947) Vermillion

Sub-committee on Mental Hygiene and Child Welfare

F. W. HAAS, M.D. (1947) Yankton

J. D. BAILEY, M.D. (1948) Rapid City

G. ZIMMERMAN, M.D. (1949) Sioux Falls

Sub-committee on Syphilis Control Program,

U.S.P.H. Service

GILBERT COTTAM, M.D. (1949) Pierre

F. J. TOBIN, M.D. (1947)....... Mitchell

ANTON HYDEN, M.D. (1948) Sioux Falls

NECROLOGY

MAGNI DAVIDSON, M.D. (1947) Brookings

W. G. MAGEE, M.D. (1948) Watertown

R. A. WEBER, M.D. (1949) .. Mitchell

MEDICAL BENEVOLENCE

C. E. SHERWOOD, M.D. (1947) Madison

G. A. STEVENS, M.D. (1948) Sioux Falls

J. C. SHIRLEY, M.D. (1949) Huron

SPECIAL COMMITTEES

RADIO BROADCAST

R. E. JERNSTROM, M.D Rapid City

S. M. HOHF, M.D. Yankton

L. J. PANKOW, M.D ... Sioux Falls

EDITORIAL

D. S. BAUGHMAN, M.D. Madison

J. C. SHIRLEY, M.D Huron

J. C. OHLMACHER, M.D Vermillion

C. E. SHERWOOD, M.D. Madison

GILBERT COTTAM, M.D. Pierre

WM. DUNCAN, M.D. Webster

F. S. HOWE, M.D Deadwood

R. G. MAYER, M.D Aberdeen

MEDICAL LICENSURE

LYLE HARE, M.D. Spearfish

J. D. ALWAY, M.D. Aberdeen

GILBERT COTTAM, M.D. ... Pierre

ADVISORY TO WOMEN’S AUXILIARY

C. E. SHERWOOD, M.D. Madison

WM. SAXTON, M.D. _..._ Huron

C. E. ROBBINS, M.D. Pierre

ALLIED GROUPS

F. C. TOTTEN, M.D. Lemmon

R. A. WEBER, M.D Mitchell

J. A. KITTLESON, M.D ... Sioux Falls

MILITARY AFFAIRS

H. E. DAVIDSON, M.D Lead

I. L. SCHUCHARDT. M.D. Aberdeen

A. A. LAMPERT, M.D. Rapid City

RADIOLOGY

N. J. NESSA, M.D. Sioux Falls

P. V. McCarthy, M.D. .. Aberdeen

J. H. LLOYD, M.D. ..... Mitchell

248

The Journal Lancet

SPAFFORD MEMORIAL FUND
FOR SCHOLARSHIP AT UNIVERSITY OF SOUTH DAKOTA

J. C. OHLMACHER, M.D. Vermillion

MEDICAL SERVICE AND PUBLIC RELATIONS

G. E. WHITSON, M.D. Madison

N. J. NESSA, M.D Sioux Falls

WM. SAXTON, M.D. Huron

PREPAYMENT AND INSURANCE PLANS

H. R. BROWN, M.D. ... Watertown

C. E. ROBBINS, M.D Pierre

R. E. JERNSTROM, M.D. Rapid City

R. G. MAYER, M.D. Aberdeen

C. E. SHERWOOD, M.D. Madison

WM. DUNCAN, M.D. Webster

COMMITTEE ON UNIVERSITY OF SOUTH DAKOTA
FOUR-YEAR MEDICAL SCHOOL

C. E. ROBBINS, M.D. Pierre

D. S. BAUGHMAN, M.D. Madison

F. S. HOWE, M.D Deadwood

NATIONAL LEGISLATION

F. S. HOWE, M.D Deadwood

R. G. MAYER, M.D Aberdeen

H. R. BROWN, M.D Watertown

C. E. ROBBINS, M.D. Pierre

J. L. CALENE, M.D. _ Aberdeen

RURAL MEDICAL SERVICE

A. P. PEEKE, M.D. Volga

C. M. KERSHNER, M.D. Brookings

M. M. MORRISSEY, M.D. ... ... Pierre

MILITARY SERVICE

FARIS PFISTER, M.D. Webster

L. W. TOBIN, M.D. Mitchell

STANLEY OWEN, M.D. Rapid City

FRANK E. BOYD, M.D Flandreau

ANTON HYDEN, M.D. .. Sioux Falls

M. W. PANGBURN, M.D Miller

A. P. REDING, M.D. Marion

Advisory to State Board of Health

OPHTHALMOLOGY AND OTOLARYNGOLOGY

H. D. NEWBY, M.D. Rapid City

C. M. KERSHNER, M.D Brookings

O. J. MABEE, M.D. ... Mitchell

ORTHOPEDICS

G. E. VAN DEMARK, M.D. Sioux Falls

OWEN KING, M.D Aberdeen

W. H. KARLINS, M.D. . Webster

SOCIAL SECURITY

N. WELLS STEWART, M.D Lead

A. J. SMITH, M.D Yankton

M. M. MORRISSEY, M.D. Pierre

MATERNAL AND CHILD WELFARE

E. A. PITTENGER, M.D. Aberdeen

E. T. LIETZKE, M.D Beresford

L. J. LERAAN, M.D. Sioux Falls

INDUSTRIAL HEALTH

R. B. FLEEGER, M.D .... Lead

R. J. JACKSON, M.D. Rapid City

R. W. MULLEN, M.D. Sioux Falls

E. M. I. C.

R. E. JERNSTROM, M.D. Rapid City

A. P. PEEKE, M.D. Volga

C. E. LOWE, M.D . Mobridge

ANNUAL MEETING OF THE COUNCIL OF THE
SOUTH DAKOTA STATE MEDICAL
ASSOCIATION

First Session, Saturday, June 1, 1946
The first meeting of the council was held in the Alonzo
Ward Hotel at 4 P.M., June 1, 1946, and was called to order
by the Chairman, Dr. C. E. Robbins. On roll-call the follow-
ing officers and councilors were present: President, Wm. Dun-
can, Webster; President-elect, F. S. Howe, Deadwood; Vice
President, H. R. Brown, Watertown; Secretary-Treasurer, R. G.
Mayer, Aberdeen; Delegate to A M. A., N. J. Nessa, Sioux
Falls; Councilors J. L. Calene, Aberdeen, First District; M. W.
Larson, Watertown, Second District; G. E. Whitson, Madison,
Third District; C. E. Robbins, Pierre, Fourth District; W. H.

Saxton, Huron, Fifth District; L. J. Pankow, Sioux Falls, Sev-
enth District; E. M. Stansbury, Vermillion, Eighth District.
Mr. Karl Goldsmith, Pierre, and Drs. Gilbert Cottam and A.
Triolo, Pierre, of the State Board of Health, were also present.

Minutes of the previous meeting held at Huron April 14th
were read and approved. Discussion of care of veterans by
civilian physicians followed. The secretary read copies of the
letter which he had sent to President Weeks and Dean Ohl-
macher at the request of the council inviting Dr. Victor John-
son, Secretary of the Council on Medical Education and Hos-
pitals of the A.M.A., to Vermillion to survey plans for the
proposed Four-Year Medical School. President Weeks’ reply
together with a copy of a letter he had received from Dr. Fred
C. Zapffe, Secretary of the Association of American Medical
Colleges, was read, stating that it would be better to wait until
plans had taken a more concrete form. Dr. Duncan read an
editorial from the Educational Number of the Journal of the
A.M.A. regarding new medical schools, and after considerable
discussion a motion was made by L. J. Pankow, seconded by
J. L. Calene, that a copy of Dr. Victor Johnson’s letter to Dr.
Duncan be sent to President Weeks with reiteration of the
council’s request for consideration of our previous letter. Dr.
Stansbury moved that the motion made by Dr. Pankow be
tabled and presented at a time when Dr. Ohlmacher was pres-
ent. The motion was seconded by G. E. Whitson and was not
carried. The previous motion by Dr. Pankow was carried.

The report of the Committee on Public Policy and Legisla-
tion was read by the chairman, Dr. Duncan, and a motion was
made by Pankow, seconded by Whitson, and carried that the
report be approved. The report of the Secretary-Treasurer was
read and a motion was made by Pankow, seconded by Whit-
son, and carried that the report be accepted and referred to
the Committee on Auditing and Appropriations. The chairman
appointed G. E. Whitson, Madison; J. L. Calene, Aberdeen;
and W. H. Saxton, Huron; to the Committee on Auditing and
Appropriations. On motion the meeting adjourned to reconvene
at 8 P.M.

Second Session, June 1, 1946
The meeting was called to order by the Chairman, Dr. C. E.
Robbins, Pierre, and on roll-call the following officers and coun-
cilors were present: Drs. Wm. Duncan, F. S. Howe, H. R.
Brown, R. G. Mayer, N. J. Nessa, J. L. Calene, G. E. Whit-
son, C. E. Robbins, W. H. Saxton, J. H. Lloyd, L. J. Pan-
kow, E. M. Stansbury, R. E. Jernstrom.

Dr. Duncan introduced Mr. John F. Barker, Brookings, as
a candidate for the position of executive secretary of the South
Dakota State Medical Association. Mr. Barker talked to the
group on his experience and ideas concerning the duties of an
executive secretary and answered numerous questions. After
Mr. Barker retired, Mr. John C. Foster, Detroit, Mich., another
candidate for the position, was admitted and introduced and
he discussed his qualifications and ideas regarding the position.

Dr. Stansbury reported on the attitude of the Yankton Dis-
trict Medical Society in regard to raising the dues, and also
the plan for a contract with the Veterans Administration for
care of veterans by civilian physicians. He stated they were op-
posed to the raising of dues because they felt that members
would be lost. Dr. Brown said that the Watertown District
voted unanimously in favor of the program and increased the
dues to $50.00. Dr. Howe reported that the Black Hills Dis- j
trict was unanimously in favor of both the Veterans Program
and raising of dues and they felt that if the executive secretary
did a good job any members lost would be regained.

The report of the Committee on Publications was read by
its chairman, R. G. Mayer. A motion was made by Brown,
seconded by Howe, and carried that the report be adopted.
On motion the meeting adjourned.

Third Session, June 4, 1946
The meeting was called to order by the Chairman, C. E.
Robbins, and on roll-call the following were present: Drs. Dun-
can, Howe, Brown, Mayer, Nessa, Whitson, Robbins, Saxton,
Lloyd, Pankow, Stansbury, Jernstrom.

After considerable discussion a motion was made by Stans-
bury, seconded by Duncan, and carried that the South Dakota
State Medical Association employ Mr. John C. Foster as execu-
tive secretary. A motion was made by Pankow, seconded by
Duncan and carried that the South Dakota State Medical
Association enter into a contract with Mr. Foster for a period

August, 1946

249

of one year at an annual salary of $3600, plus his necessary
office and travel expenses at the rate of 5c per mile. A motion
was made by Duncan, seconded by Brown, and carried that the
office of the executive secretary be located in Sioux Falls. A
motion was made by Duncan, seconded by Lloyd, and carried,
that Drs. Pankow and Nessa be appointed to investigate office
and housing space in Sioux Falls. A motion was made by
Howe, seconded by Duncan, and carried, that Mr. Foster be
employed as of July 1, 1946.

A motion was made by Brown, seconded by Howe, and car-
ried, that Mr. Foster be contacted by telephone and asked to
wire acceptance, a contract to be drawn up at his convenience.
A motion was made by Duncan, seconded by Lloyd, and car-
ried, that the council authorize Drs. Pankow and Nessa any
expenses necessary in securing office and housing space for
Mr. Foster.

A motion was made by Duncan, seconded by Brown, that
Dr. Robbins be re-elected chairman of the council. A motion
was made by Howe, seconded by Jernstrom, and carried, that
nominations be closed and that a unanimous ballot be cast for
Dr. Robbins. A motion was made by Lloyd, seconded by Stans-
bury, and carried, that R. G. Mayer be re-elected secretary-
treasurer for three years. A motion was made by Howe, sec-
onded by Stansbury, and carried that Dr. Duncan be author-
ized to express the appreciation of the council to Senator Chan
Gurney for the work he has done to aid the medical profession
by securing the release from military service of doctors from
South Dakota. A motion was made by Pankow, seconded by
Howe, and carried that the council express its appreciation to
the South Dakota Senators and Representatives in Congress for
their services to the medical profession. A motion was made
by Pankow, seconded by Stansbury, and carried that the sec-
retary-treasurer be allowed the sum of $200 to cover expenses
in attending meetings in the interest of the association during
the past year.

A motion was made by Duncan, seconded by Stansbury, and
carried that the president, president-elect and secretary-treasurer
be empowered to work out details regarding the employment of
Mr. Foster as executive secretary. A motion was made by
Howe, seconded by Jernstrom and carried that a letter of appre-
ciation be sent to Dr. Gilbert Cottam for the services rendered
to the association by his secretary during the 1946 session.

After a brief discussion of plans for a meeting of the Com-
mittee on Prepayment and Insurance Plans a motion was made
by Howe, seconded by Brown, and carried that the expenses
of Mr. C. H. Crownhart, Secretary of the State Medical So-
ciety of Wisconsin, be paid to the committee meeting in Huron.
On motion the meeting adjourned.

R. G. Mayer, M.D., Secretary

REPORT OF THE PRESIDENT

1945-46

During the past year I attended meetings with the following
district medical societies:

1st district at Aberdeen, 2nd district at Watertown, 3rd dis-
trict at Volga, 6th district at Mitchell, 7th district at Sioux
Falls, 8th district at Vermillion, 9th district at Rapid City and
12th district at Milbank.

Within the state I also attended the annual meeting of the
South Dakota State Public Health Association and one meet-
ing of the governor’s State Health Committee at Mitchell.

Other meetings attended which directly concerned the busi-
ness of our association were:

1. The annual North Central Conference last November in
St. Paul. At that meeting I was elected president-elect of the
conference.

2. A special meeting of the North Central Conference in
Minneapolis to consider medical care of World War II veterans’
service connected disabilities by a contractual agreement with
the South Dakota State Medical Association.

There were several other important meetings to which I was
invited, but was unable to attend. All of these were called by
our national organization, the American Medical Association,
and were held in Chicago. However, South Dakota was repre-
sented at all of these gatherings by other officers or committee
chairmen, namely Doctor Brown, our vice president, Doctor
Mayer, our secretary, and Doctor Peeke, chairman of the Com-
mittee on Rural Health.

In addition to attending these gatherings of the medical pro-
fession, I have discussed the subject of socialized medicine with
several lay groups, including the Sioux Falls Rotary Club,
through an invitation from my good friend and past president
of our association, Doctor Nessa.

An invitation to speak on the same subject before the annual
meeting of the state pharmacists was of necessity declined, but
through the assistance of Doctor Pankow, an able speaker from
Sioux Falls, Doctor J. A. Nelson, took care of this.

Through these contacts with lay groups, I have reached the
conclusion that the people are interested in the subject of social-
ized medicine, but when our side of it is presented to them
they want no part of it. Consequently it might be well to con-
sider the formation of a speakers’ bureau in order that a much
greater part of the public could be reached in this way.

Throughout the past year I have endeavored to have the
present status of the proposed four-year medical school at the
University of South Dakota clarified, in order that this house
of delegates of our state association would have some definite
information wherewith to form an opinion of its chances for
success or failure.

With regret, I must report that those in authority at the
university have elected to proceed with their plans without seek-
ing the advice of the American Medical Association council on
medical education and hospitals. Consequently, on this impor-
tant subject there is very little to offer except the enthusiasm
of Doctors Weeks and Ohlmacher, which has apparently been
inspired largely by Doctor Zapffe, secretary of the American
Association of Medical Colleges.

In saying this, I am definitely not questioning the sincerity
of purpose demonstrated by Doctors Weeks and Ohlmacher,
but do feel that by this time they should have had at least a
preliminary survey of their plans by the council which repre-
sents organized medicine in such matters.

Many years ago and for very good reasons, the American
Medical Association established a council on medical education
and hospitals. Its primary purpose at that time, and this has
not changed as of today, was to establish minimum educational
standards for medical schools, in order to protect the public
from unqualified practitioners.

Through the years since then, they have demonstrated the
sincerity of their purpose to such an extent that today there
are only two states among our forty-eight which recognize for
licensure graduates of a school which is not approved by this
American Medical Association council.

Our state association is not only a subsidiary, but an integral
part of the American Medical Association. Consequently as
delegates to this meeting you definitely have the authority to,
and the responsibility of, requesting an immediate investigation
of this proposed four-year school by the designated authorities
of the American Medical Association’s council on medical edu-
cation and hospitals.

At the several district meetings attended during this year,
I have also tried to point out that our secretary’s office is greatly
in need of additional personnel, and that a full-time executive
secretary should be a part of our organization.

In conclusion, and in support of this contention the follow-
ing is quoted from the last News Letter issued by the Ameri-
can Medical Association’s council on medical service and public
relations issued May 24, 1946:

"Medical organizations throughout the country are getting
back to normal but that isn’t enough.

Many local medical societies which haven’t had regular meet-
ings since the war are getting back on schedule — but that isn’t
enough.

Spring is the usual season for many state and district med-
ical meetings but the usual meetings are not enough.

Indeed nothing short of all-out, intense, well directed local
medical organizations with active, functioning committees cov-
ering each key subject, working as they have never worked
before, is going to be enough to accomplish what must be ac-
complished if American medicine is to meet the obligations
placed on it and do the job outlined by the house of delegates,
the board of trustees, the council on medical service and public
relations and the other councils and bureaus of the American
Medical Association.”

William Duncan, M.D.

250

The Journal Lancet

SECRETARY’S REPORT— 1945-46

The report of your secretary for the past year will be as
brief as possible. As usual, the number of magazines and pam-
phlets, letters received and answered, ran well into the thou-
sands. Mimeographed letters on various subjects were mailed
to the members of the South Dakota State Medical Association
during the year, and countless letters, telegrams and telephone
calls were exchanged with officers, councilors, district secretaries,
members, AM. A. officers and committee-men, members of
Congress, etc., regarding state medical association matters.

Seven medical conferences and meetings were attended. In
October I attended the Public Relations Conference called by
the Council on Medical Service and Public Relations of the
A.M.A., which was held in Chicago. The following subjects
were discussed at this conference: legislation, extension of

EMIC program, public relations, placement of medical officers,
prepaid medical care plans, rural health problems, activating
14 point constructive program of the A.M.A. for medical
care, and Veterans Administration plans.

On Feb. 7, 1946, I attended a conference of secretaries and
executive secretaries of state medical associations in Chicago
called by Medical Exhibitors, Inc., which was very instructive
regarding the planning of exhibits at state medical conventions.
Many state medical conventions by properly organizing their
exhibits pay all of their convention expenses from receipts for
exhibit space.

On Feb. 8th and 9th I attended the annual conference of
secretaries of state medical associations at Chicago, which was
called by the A.M.A. National legislative matters, public rela-
tions, rural health problems, care of veterans, medical care pre-
payment plans, etc., were discussed. On Feb. 10th I attended
the national conference on medical service at the Palmer House
in Chicago. Among others who talked on various subjects were
Mr. Cruikshank, director of the Committee on Health, A. F.
of L., who spoke on "What Labor Expects from Medicine,”
telling how labor is solidly behind the Wagner Bill, and Mr.
J. S. Jones, secretary of the Minnesota Farm Bureau Federa-
tion, who talked on "What the Farmer Expects from Medi-
cine,” stating that the Farm Bureau Federation is opposed to
the Wagner Bill. On March 2nd I attended the county offi-
cers meeting of the Minnesota State Medical Association in
Minneapolis. This was an interesting program to enlighten the
officers of the county medical societies on various subjects, such
as medical care prepayment plans, blood plasma program, care
of veterans, public relations, etc. On March 3rd I attended the
North Central Conference in Minneapolis called to discuss the
plans of the Veterans Administration for the care of veterans
by civilian physicians. South Dakota was also represented at
this conference by Drs. Wm. Duncan, H R. Brown and G. E.
Whitson. And this past month I attended the annual conven-
tion of the Minnesota State Medical Association in St. Paul.
My expenses to the Public Relations Conference in Chicago in
October were the only expenses paid for by the State Medical
Association.

The officers and council held two meetings in Huron, one
on Jan. 27th and one on April 14th. I would like to make sev-
eral suggestions for the consideration of the officers, councilors,
committeemen and members of the association. First, I believe
that the rank and file of the members of the South Dakota
State Medical Association do not have enough authentic knowl-
edge about what is going on in the state and nation regarding
legislative matters, public relations, medical care plans and med-
ical economis. As far as the national problems are concerned,
this could be obviated partly if they would only read the edi-
torials and comments and the organization section of the Jour-
nal of the A.M.A. every week. However, for the state prob-
lems, I would like to see a meeting of the district society offi-
cers, similar to the meeting which I attended in Minnesota.
Incidentally, I also urge the secretaries of the component dis-
trict societies to be more prompt in sending in their reports,
and that their reports be complete, including list of officers and
delegates, active or paid-up members, honorary members, mem-
bers in the armed services, and non-members. It is very diffi-
cult to keep records up to date unless all of this information
is sent in promptly.

And then I believe it would help if we had a state medical
association bulletin published about once a month. News, edi-
torials, comments and reports of committees could be included

which would be of interest to the physicians in South Dakota.
I have no doubt that advertisements could be secured which
would more than cover the cost involved. However, this could
not be successful unless there would be cooperation and work
by all those concerned. It could not be a one-man proposition.

And finally, I believe that our committees should function
throughout the year and not wait until just before the Annual
Convention to get together or write the various committeemen
and then make a routine report.

Analyzing the list of medical practitioners in the state makes
one feel that we should make more strenuous efforts to induce
more physicians to come to South Dakota to practice. There
are 353 physicians in active practice in the state. Of these
268 are active (paid-up) members of the South Dakota State
Medical Association. Only 149 of the 353 are under 50 years
of age, 204 being over 50, 113 being over 65. There are 82
chiropractors and 61 osteopaths practicing in South Dakota.

The following is the analysis of the active membership, show-
ing comparison of last year’s figures at convention time, the

total membership attained by the close o

f 1945, and the

1946

figures

, not including those in

the armed

services.

May

December

May

District

1945

1946

Aberdeen

..... 28

II.

Watertown

Ill

Madison ...

IV.

Pierre

Huron

VI.

Mitchell

VII.

Sioux Falls

..... 42

VIII

Yankton

.... 27

IX.

Black Hills

Rosebud

XI.

Northwest

XII.

Whetstone Valley . .....

Totals 231

256

268

R. G. Mayer, Secretary

TREASURER’S REPORT— 1945-46

Checking Account

Balance on Hand, June 7, 1945

#3,632.43

Receipts:

Interest, U. S. Bond

---#

12.50

1945 Dues (22 members)

330.00

1946 Dues (267 members)

4,005.00

1946 Dues (part payment)

3.75

Total

4,351.25

Total

#7,983.68

Disbursements:

Legislative Fund

500.00

Journal Lancet

708.00

Benevolent Fund

123.50

Delegate Expenses A M. A.

66.83

Expenses Conference (Brown)

56.91

Dues — Conf. Presidents

10.00

Council Expenses

286.10

Karl Goldsmith, Retainer

300.00

Secretary’s Salary (11 mo.)

550.00

Secretary's Travel Expenses

68.35

Secretary’s Office Expenses:

Bond S

10.00

Bank Charges

3.43

Soc. Sec. Tax

6.00

Postage

4.10

Telegrams

16.90

Stenographic Exp.

and Mimeograph

110.00

Stationery, Cards

96.12

Telephone (Duncan)

5.80

Total

252.35

Total Disbursements #2,922.04

Balance on Hand, June 1, 1946

5,061.64

Total #7,983.68

R. G. Mayer, Treasurer

August, 1946

251

A.M.A. DELEGATE S REPORT TO THE COUNCIL
1944-45

The meeting was called to order, 10 A.M. Monday, Decem-
ber 1, 1945, at Palmer House Hotel, Chicago, Illinois. The
roll call showed most members present.

The annual selection of recipient of Distinguished Service
Award was voted to Dr. Minot of Boston for his work in
pernicious anemia. Dr. Abt and Dr. Carlson of Chicago were
close contenders.

The speakers address by Dr. Shoulders of Nashville, Ten-
nessee, was well given and accepted and I am sure those of
you who read his address will formulate a mental picture of
our new president-elect.

The address by president Dr. Herman Kretschmer of Chi-
cago, followed by the address of president-elect Roger Lee of
Boston, were well accepted also and have since been published
in Journal A.M.A.

The new officers for 1946 are as follows: President, Dr.
Roger I. Lee of Boston, Massachusetts; president-elect, Dr.
Harrison Shoulders of Nashville, Tennessee; vice president,
Dr. William R. Mullovey of San Francisco; secretary, Dr. Olin
West of Chicago; treasurer. Dr. J J. Moore of Chicago;
speaker, Dr. Roy Fouts, Omaha, Nebraska; vice speaker, Dr.
F. F. Borzell of Philadelphia; editor, Dr. Morris Fishbein, Chi-
cago, and business manager, Will C. Braun, Chicago.

Major General Hawley of Washington was present and de-
livered an address which was well accepted. He committed him-
self as definitely against social medicine. He has been in the
army 30 years and has a good medical background inasmuch
as his father and grandfather were doctors of medicine. He
comes from Indiana.

The evening of the first day was devoted to installation of
president-elect Lee and presentation of medal to retiring presi-
dent Herman L. Kretschmer and also presentation of medal
to Brigadier General Fred Rankin as representative of the
Army Medical Service.

Many resolutions were introduced from the various states,
pertaining to the pending health problems, with special reference
to compulsory health matters as outlined in President Truman’s
recent public health program.

At long last, the A.M.A. House of Delegates has scrapped
its traditional negative, view-with-alarm attitude and, at the
recent Chicago session, formulated a positive, aggressive policy,
boldly asserted the position of medicine and inspired new hopes
for the future.

Without a dissenting vote, the house instructed the Board
of Trustees and the Council on Medical Service and Public
Relations to develop immediately "a specific national health
program with emphasis upon the nation-wide organization of
locally administered prepayment plans.” Observers hailed this
action as providing a constructive, definite program for Ameri-
can medicine, and as a reply to, and an alternative for, Presi-
dent Truman’s recent proposals and the Wagner-Murray-
Dingell and Pepper Bills. On every hand, it was regarded as
the positive plan which many physicians have been urging for
some years.

The National Physicians Commission has also recently be-
come very active relative to the implications of the Wagner
Bill and our president, Dr. Duncan, can bring us informative
news on this subject.

There was again this year a resolution made by the Cali-
fornia delegation to limit the functions of the editor to full-
time service on the journal. This brought up rather heated
and controversial oratory, especially from the southern states
and on ballot as usual the resolution was voted down.

It may well be that with the present change of speaker, the
geographical sentiments will become more western and northern
in character, in the deliberation of this august body.

Again it was a pleasure for me to represent our state and
am sure that my follower will find it likewise.

N. J. Nessa, 1945 A.M.A. Delegate

PROCEEDINGS OF THE 65TH ANNUAL
MEETING OF THE HOUSE OF DELEGATES
South Dakota State Medical Association
First Session, June 2, 1946

The meeting of the House of Delegates was called to order
by president William Duncan, Webster, at 1 P.M., Sunday,

June 2, 1946, in the Alonzo Ward Hotel Ballroom, Aberdeen.
Dr. Duncan introduced the two guests present who were can-
didates for the position of executive secretary of the South
Dakota State Medical Association, Mr. John F. Barker, Brook-
ings, S. D., and Mr. John C. Foster, Detroit, Mich.

On roll-call the following were present: President, Wm.

Duncan, Webster; president-elect, F. S. Howe, Deadwood;
vice president, H. R. Brown, Watertown; secretary-treasurer,
R. G. Mayer, Aberdeen; councilors J. L. Calene, Aberdeen;
M. W. Larson, Watertown; G. E. Whitson, Madison; C. E.
Robbins, Pierre; W. H. Saxton, Huron; J. H. Lloyd, Mitchell;
L. J. Pankow, Sioux Falls; E. M. Stansbury, Vermillion; R. E.
Jernstrom, Rapid City; C. E. Lowe, Mobridge; D. A. Gregory,
Milbank; Delegates or Alternate Delegates Leo Graff, Britton;
J. D. Alway, Aberdeen; S. J. Walters, Watertown; E. S.
Watson, Brookings; M. M. Morrissey, Pierre; Paul Tschetter,
Huron; N. J. Nessa, Sioux Falls; C. J. McDonald, Sioux
Falls; G. A. Stevens, Sioux Falls; J. A. Nelson, Sioux Falls;
A. P. Reding, Marion; V. I. Lacey, Yankton; W. A. Dawley,
Rapid City; R. B. Fleeger, Lead; Lyle Hare, Spearfish; W. L.
Meyer, Sanator; F. C. Totten, Lemmon; W. H. Karlins,
Webster.

The president then called for the minutes of the previous
meeting and a motion was made by Whitson, seconded by Mc-
Donald, and carried that the minutes of the previous meeting
as they appeared in the September 1945 issue of the Journal
Lancet be approved. The president made the following ap-
pointments of committees: Committee on reports of officers,

C. J. McDonald, Sioux Falls, A. P. Reding, Marion, Leo
Graff, Britton; committee on resolutions and memorials, C. E.
Robbins, Pierre, E. S. Watson, Brookings, J. H. Lloyd,
Mitchell; committee on nominations, R. E. Jernstrom, 9th dis-
trict, chairman, J. D. Alway, 1st district, M. W. Larson, 2nd
district, G. E. Whitson, 3rd district, M. M. Morrissey, 4th
district, W. H. Saxton, 5th district, O. J. Mabee, 6th district,
L. J. Pankow, 7th district, A. P. Reding, 8th district, F. C.
Totten, 11th district, W. H. Karlins, 12th district; committee
on credentials, N. J. Nessa, Sioux Falls, J. L. Calene, Aber-
deen, Lyle Hare, Spearfish; committee on amendments to con-
stitution and by-laws, W. H. Saxton, Huron, R. B. Fleeger,
Lead, E. V. Auld, Plankington.

The address of the president and the president-elect fol-
lowed. The reports of the officers weie then given: president
Wm. Duncan, president-elect F. S. Howe, vice president H. R.
Brown, secretary-treasurer R. G. Mayer, chairman of the coun-
cil C. E. Robbins. N. J. Nessa, Sioux Falls, read his report
as delegate to the A.M.A.

Dr Gilbert Cottam, superintendent of the State Board of
Health, was to report on the hearings held by the Senate Com-
mittee on Education and Labor on the Wagner-Murray-Dingell
Bill but said that he thought it unnecessary to make such a
report as the Journal of the A.M.A. published full reports of
the entire proceedings. At this time Dr. Duncan read a letter
from the personnel officer of the Veterans Administration in
Sioux Falls regarding assistance by physicians to disabled vet-
erans. Dr. Einar C. Andreassen, assistant medical director,
Veterans Administration, Minneapolis, Minn., then gave a fine
address, outlining the work of the Veterans Administration in
a general way as well as the medical program and emnhasizing
the fact that cooperation of the civilian medical profession is
sought by the Veterans Administration.

After a short recess Dr. Duncan read a letter from the
state representative of the National Foundation for Infantile
Paralysis, urging members to attend a meeting of the states
in this area to be held in Wyoming. The reports of the Stand-
ing and Special Committees were then heard and the following
councilors made reports for their districts: J. L. Calene, first

district; M. W. Larson, second district; G. E. Whitson, third
district; C. E. Robbins, fourth district; W. H. Saxton, fifth
district; J. H. Lloyd, sixth district; L. J. Pankow, seventh dis-
trict; E. M. Stansbury, eighth district; R. E. Jernstrom, ninth
district; D. A. Gregory, twelfth district.

Dr. Duncan introduced a past president of the South Da-
kota State Medical Association, Dr. F. E. Clough, who now
resides in California. Dr. Clough gave a short talk about the
activities of the medical society in California and what their
experiences had been in trying to develop satisfactory programs
during the war.

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The report of the Committee on Auditing and Appropria-
tions and the Budget was presented by the committee chairman,
G. E. Whitson. A motion was made by Howe, seconded by
Stansbury, and carried that it be approved. A motion was
made by Stansbury, seconded by Lloyd, and carried that Dr.
B. A. Bobb, formerly of Mitchell, be made an honorary mem-
ber and be recommended to honorary fellowship in the Ameri-
can Medical Association. A motion was made by Howe, sec-
onded by Stansbury, and carried that those members named
by district medical secretaries as honorary members be elected
as honorary members of the South Dakota State Medical
Association.

A motion was made by Jernstrom, seconded by Robbins, and
carried that the annual dues be raised to $50.00 for 1947 and
that the council be empowered to make adjustments to mem-
bers as they see fit, with Reding and Lacey, delegates of the
Yankton district voting "No”. A motion was made by Howe,
seconded by Robbins, and carried that the South Dakota State
Medical Association enter into a contract with the Veterans
Administration to care for service-connected disabilities of vet-
erans. On motion the meeting adjourned.

Second Session, June 3, 1946

The meeting was called to order by the president, Dr. Wm.
Duncan, and on roll-call the following were present: Duncan,

Howe, Brown, Mayer, Calene, Larson, Whitson, Robbins, Sax-
ton, Lloyd, Pankow, Stansbury, Jernstrom, Graff, Alway,
Walters, Watson, Nessa, McDonald, Stevens, Nelson, Reding,
Lacey, Dawley, Fleeger, Hare, Meyer, Totten, Karlins.

Before proceeding with the regular order of business Dr.
Duncan introduced Dr. Goldie Zimmerman, Sioux Falls, who
told the group about the survey being conducted by the Ameri-
can Board of Pediatrics with the cooperation of several other
organizations to find out the conditions of child health in our
state. Dr. Triolo, executive secretary of this committee in South
Dakota, endorsed the comments made by Dr. Zimmerman and
explained that the object of this survey is to get the facts,
as there are no true and accurate statistics concerning child
health, which has led to many comments regarding the in-
adequacy of child health. He said that questionnaires with
explanatory data will be sent to each physician individually in
South Dakota and asked the House of Delegates to give the
survey its official approval. A motion was made by Whitson,
seconded by Karlins, that the House of Delegates officially
approve the survey being conducted by the American Board of
Pediatrics of child health conditions in South Dakota and urge
the cooperation of all physicians in the state. The motion was
carried.

The chairman of the Nominating Committee, R. E. Jern-
strom, made the following nominations:

President — F. S. Howe, Deadwood.

President-Elect — H. R. Brown, Watertown; J. D. Alway,
Aberdeen.

Vice President — J. L. Calene, Aberdeen; W. H. Karlins,
Webster.

Delegate to A M. A. — William Duncan, Webster.

Alternate Delegate to A M. A. — H. R. Brown, Watertown.

Councilors — 9th District — R. E. Jernstrom, Rapid City.

10th District — R. J. Quinn, Burke.

11th District — A. W. Spiry, Mobridge.

12th District — D. A. Gregory, Milbank.

A letter was read by Dr. Jernstrom from Rapid City extend-
ing an invitation to the Association to hold their 1947 meeting
there. A motion was made by Pankow, seconded by Robbins,
and carried that the by-laws be suspended and that unanimous
ballot be cast for Dr Brown as President-Elect, Dr. Calene
as Vice President, the delegates and councilors as presented by
the nominating committee. A motion was made by Whitson,
seconded by Lloyd, and carried that the invitation from Rapid
City be accepted and that the annual meeting be held in Rapid
City in 1947. The report of the Credentials Committee was
given by Dr. Nessa and a motion was made by Stansbury, sec-
onded by Lloyd, and carried that the report be adopted.

The report of the Committee on Amendments to Constitu-
tion and By-Laws was presented by Dr. Saxton, who stated
that the committee had taken no action on the matter of alter-
nate councilors. A motion was made by Whitson, seconded by
Stansbury and carried that the report be accented. It was
moved by Pankow, seconded by Calene, that the Committee

on Amendments to Constitution and By-Laws be instructed to
bring in at the next session of the House of Delegates a suit-
able amendment which will enable a district society to have
representation on the council by an alternate in the unavoidable
absence of the regular councilor. It was moved by Stansbury,
seconded by Morrissey, that the motion of Pankow be tabled.
Carried. The Committee on Reports of Officers recommended
that the reports be accepted. Motion carried.

The chairman of the Committee on Resolutions and Mem-
orials, C. E. Robbins, then presented the report of his com-
mittee. The committee wished to commend the scientific pro-
gram and extend thanks to Drs. Duncan, Howe and Mayer
for their efforts in arranging it. It was moved by Stansbury,
seconded by Lloyd, and carried that the report be adopted. The
committee recommended that the matter of House Bill No. 21
be referred to the Legislative Committee, with authority to act
as they deem best. They further recommended that the council
appropriate funds as necessary to prosecute violators and con-
tact the osteopaths and chiropractors as stated in report of
Committee on Public Policy and Legislation. The committee
recommended that the matter of sending a bi-monthly bulletin
to all physicians be left to the council. It was moved by Whit-
son, seconded by Saxton, and carried that the report be
accepted. The committee recommended that the report of the
Committee on Medical Economics be referred to the Legislative
Committee for any necessary action. They felt that the en-
abling act should not be necessary if the "Wisconsin” plan for
pre-payment insurance be adopted. A motion was made by
Whitson, seconded by Calene, that the report be approved.
Carried.

The committee recommended that the resolution regarding
the passage at the next general election of the bill known as
Senate Bill No. 62 be adopted. It was moved by Whitson,
seconded by Lloyd, that the report be accepted. Carried. The
committee recommended that the resolution regarding operation
of the mobile x-ray unit be adopted. It was moved by Jern-
strom, seconded by Whitson, that the report be accepted.
Carried.

The committee recommended that the report on county or
district full-time modern public health service be achieved be
accepted and the resolution adopted. A motion was made by
Saxton, seconded by Howe, and carried that the report be
accepted. The committee recommended that the report of the
Committee on Cancer be adopted and that the council be
authorized to appoint this committee as suggested. Motion was
made by Stansbury, seconded by Whitson, and carried that
the report be accepted. The committee moved that the report
of the Committee on Syphilis Control be accepted. Motion
seconded by Howe and carried. The committee moved that the
report of the Committee on Necrology be accepted, pending
confirmation of the report from Dr. Cottam’s office. Motion
seconded by Lloyd and carried. The committee moved the
acceptance of the report of the Committee on Medical Benev-
olence and recommended that the secretary be instructed to
send check to the Benevolent Fund for 50c per member. Mo-
tion seconded by Stansbury and carried. The committee moved
the acceptance of the report of the Radio Committee. Motion
seconded by Lloyd and carried. The committee moved accept-
ance of the report of the Committee on Military Affairs. Mo-
tion seconded by Whitson and carried. It was moved by the
committee that the report of the Committee on Radiology be
accepted. Motion seconded by Stansbury and carried. It was
moved that the report of the Committee on Medical Service
and Public Relations be accepted. Motion seconded by Howe
and carried.

The committee recommended that the present Committee on
Prepayment and Insurance Plans, including President Duncan,
be authorized to go ahead and set up such a plan to be rati-
fied by the Council and House of Delegates. Motion seconded
by Calene and carried. At this time Dr. A. W. Adson, of the
Council on Medical Service and Public Relations, A.M.A.,
sooke a few minutes regarding prepayment and insurance plans.
He stated that there are a number of plans in operation. The
type of benefits should be determined and the committee should
meet with a committee of the insurance group, express their
wants and discuss premium structure. This plan should be
endorsed by the State Society. Any plan supported by the
State Medical Association should receive the endorsement of

August, 1946

253

the A.M.A. If we are to meet the federal challenge it is nec-
essary that you have a plan which will meet with the approval
of the public. The voluntary plan is the best from the busi-
ness point of view.

It was recommended that the report of the Committee on
Crippled Children be accepted. Motion seconded by Jernstrom
and carried. It was moved that the report of the Committee
to Study Reasons for Rejection of Selectees in South Dakota
be accepted, with thanks to Dr. Triolo and Department of
Health for these statistics. Motion seconded by Stansbury and
carried.

It was moved that the report of the committee on the four-
year medical school at the University of South Dakota be ac-
cepted and that the State Association write to Dr. Victor John-
son to investigate the school. Motion seconded by Lloyd. Dr.
Stansbury suggested that we leave the matter of the medical
school up to the President and moved that the motion to accept
the report be tabled. This was followed by a discussion regard-
ing the Medical School and the motion to accept the report
carried.

It was moved that the report of the Committee on National
Legislation be accepted and that the House of Delegates go
on record as definitely opposed to the Wagner-Murray-Dingell
Bill, and endorsing the National Physicians Committee. Motion
seconded by Howe and carried. It was moved that the report
of the Editorial Committee be accepted. Seconded by Whitson
and carried. It was moved that the report of the Committee
on Medical Defense be accepted. Motion seconded by Stans-
bury and carried. It was moved that the report of the E.M.I.C.
Committee be accepted. Seconded by Lloyd and carried. It was
moved that the report of the Committee on the Spafford Mem-
orial Prize be accepted. Seconded by Stansbury and carried.
On motion the report of the Committee on Education and
Hospitals was accepted, seconded by Howe and carried. The
committee moved that the report of the Committee on Rural
Health be accepted and recommended that the South Dakota
State Medical Association use its best influence to promote the
passage of the Hospital Licensure Bill at the referendum next
fall. Motion seconded by Whitson and carried.

Under new business Pankow moved that Article 9 of the
constitution be amended to add after the word "council” the
words "or regularly elected alternate councilor.” The motion
was seconded by Calene. This matter will be presented to the
proper committee and come up for consideration at the next
annual session. On motion the meeting adjourned.

Chairman of Council’s Report to House of Delegates

During the current year two meetings of the council were
held, the first on January 27 at Huron. Dr. M. W. Larson of
Watertown was elected to fill the unexpired term of Dr. H. R.
Brown of the Watertown district. The death of R. V. Overton
of Winner left the Rosebud district without a councilor. It was
thought unadvisable to replace him at this time, but the Rose-
bud district was asked to elect someone to be seated at the
June 1946 meeting.

A report on the plans for the four-year medical school was
made by Dr. J. C. Ohlmacher, Dean, and President I. D.
Weeks of the University. The council went on record as sup-
porting this four-year medical school plan only in case a class
"A” school was assured. Doctor Brown reported on the na-
tional conference on prepayment plans which he attended in
Chicago in November. Doctors Duncan and Robbins reported
on the National Conference called by the National Physicians
Committee in St. Louis. The purpose of this conference was
to instruct two representatives from each medical society on the
procedure to follow in combating the Wagner-Murray-Dingell
Bill.

At the second meeting held in Huron on April 14, 1946,
the main topic of discussion was the proposed contract with the
Veterans Administration. Doctors Duncan, Brown, Whitson
and Mayer had recently attended a meeting in Minneapolis
relative to this matter. It was the consensus of the meeting
that a uniform fee bill be arranged with the Veterans Bureau
to conform with the four other neighboring states, to care for
service-connected disability of veterans. The matter of hiring
a full-time executive secretary came up. The council decided
to have a vote of each district as to whether other doctors
would be willing to have the dues raised to $50.00 to care

for the expenses of the secretary. It was decided that the pros-
pective candidates for this position be asked to meet with the
council and the house of delegates in Aberdeen in June.

The matter of the four-year medical school again came up
and it was decided that the council request President Weeks of
the University and Doctor Ohlmacher, Dean of the Medical
School, to invite Dr. Victor Johnson, secretary of the Council
on Medical Education of the American Medical Association,
to Vermillion to survey the plan of the proposed four-year med-
ical school and to meet with representatives of the University
and representatives of the South Dakota State Medical Associa-
tion. It was decided to hold the 1946 meeting in Aberdeen,
June 1 to 4.

C. E. Robbins, M.D., Chairman of Council

Report of Committee on Auditing and Appropriations

The committee on Auditing and Appropriations met at 10:30
P.M., June 1, 1946, and found the books of the treasurer cor-
rect. The following budget was adopted and is presented for

approval:

Estimated Income $4,500.00

Estimated Disbursements:

Retainer Fee — Attorney $ 300.00

Secretary’s Salary 600.00

Journal Lancet 750.00

Secretary’s Office Expenses 300.00

Secretary’s Traveling Expenses 150.00

Council Meetings Expenses 300.00

Benevolent Fund 150.00

Legislative Fund 500.00

North Central Conference 50.00

Expenses for State Meeting 1,900.00

Miscellaneous 325.00

Total $4,425.00

Geo. E. Whitson, M.D., Chairman
John L. Calene, M.D.

W. H. Saxton, M.D.

Report of Committee on Credentials

The Committee on Credentials makes the following report:

1. Number of officers present — 4.

2. Delegate to A.M.A. present.

3. Alternate delegate to A.M.A. absent.

4. All councilors present and each district represented ex-

cept district 10.

5. Councilor at large absent.

6. Number of delegates present — 15.

7. Total number of members registered by 4 P.M., June

3rd— 144.

8. Number of guests present — 21.

9. Women’s Auxiliary — 27.

N. J. Nessa, M.D., Chairman
John L. Calene, M.D.

Lyle Hare, M.D.

REPORTS OF STANDING COMMITTEES
Committee on Public Policy and Legislation

The subject of public policy can be covered briefly by recom-
mending that our State Association inaugurate an active public
relations program according to the recommendations of the
American Medical Association. The details of how such a pro-
gram should be carried out have been published by the Ameri-
can Medical Association and so are readily available and will
not be repeated in this report.

Furthermore it is recommended that our association co-operate
in every way possible with the American Medical Association,
and especially follow the leadership of the Council on Medical
Service and Public Relations. In doing this the single, most im-
portant step, to be taken immediately is the establishment of
some type of voluntary prepaid medical insurance which would
be available throughout the state, and which would meet the
minimum requirements for such insurance recently established
by the American Medical Association.

Concerning state legislation, it is the wish of this committee
that every individual member more fully realize and accept his
responsibility in such matters. Mr. Goldsmith, our attorney
and lobbyist, has repeatedly said the most effective way to in-

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fluence legislation is for every individual physician to personally
contact his own representative and senator and express his views.

At the last legislative session a particularly obnoxious bill
was passed, largely because of indifference on the part of the
majority of our members. We refer to what was known as
House Bill No. 21, and which provides that the trustees of a
county hospital shall not discriminate between licensed doctors.
This means that osteopaths, chiropractors, optometrists, etc.,
cannot be excluded from the staff of a county hospital. At the
present time, there are only one or two hospitals affected by
this law, but if and when the Hill-Burton bill is passed by Con-
gress, it is quite likely that more county hospitals will be estab-
lished. At any rate the law establishes a dangerous precedent
and so this committee recommends that our Association do its
utmost to have this law amended, modified or better yet, nulli-
fied at the next State legislative session.

Several years ago the State Association was instrumental in
having a Basic Science Law passed. However, no provision was
made to adequately finance investigation and prosecution of
violators. Consequently, it is recommended that the State Asso-
ciation appropriate sufficient funds from its treasury for this
purpose and that the Secretary contact the State Osteopathic
Association and the State Chiropractic Association to deter-
mine whether or not they are willing to do likewise.

William Duncan, M.D., Chairman

Committee on Medical Defense

In 1940 the medical defense committee of that year brought
in a report that was tabled. Among other things this report
recommended that in each district of the State Association one
member would be appointed who would investigate any mal-
practice suits brought to court in his district. No further action
was taken on this report.

In March 1945 an insurance company, with which the ma-
jority of the members of the southeastern part of the state were
insured, notified its policyholders in South Dakota that it
would no longer write malpractice insurance in this state. The
reason given was that it had taken and was taking too many
losses in this state. The Medical Defense Committee for the
year 1945 recommended to the House of Delegates that the
tabled motion of 1940 be reviewed and reported at the next
meeting.

The present committee has reviewed this motion and believes
it no longer feasible to act on its recommendations for the fol-
lowing reason: in 1942 our Supreme Court adopted a rule
which became effective Jan. 1, 1943. This rule provided that
whenever in a civil or criminal proceedings issues arise upon
which the Court deems expert evidence is desirable, the Court,
on its own motion, or on the request of any party, may appoint
one or more experts, not exceeding three, to testify at the trial.
If in a malpractice suit the Court, or either of the parties
wished an investigation made by a noninterested medical prac-
titioner, the machinery is set up by this order for the calling
of such an expert and such expert or experts might, when so
authorized by the court, make a physical examination. After
the examination the experts may be required to file a written
report.

The present Committee believes this to be a big advance in
malpractice court procedure and eliminates the necessity of act-
ing on the 1940 report. It is also the intention of this Com-
mittee by this report to call attention to the new rules of the
State Supreme Court.

C. J. McDonald, M.D., Chairman

Committee on Medical Economics

This is an election year and the members of the South Da-
kota State Medical Association should get in touch with the
candidates for the State Legislature and endeavor to find out
their attitude toward organized medicine. There will be the
usual crop of bills introduced into the legislature from the vari-
ous cults. These will require opposition.

We feel that the enabling act which was introduced at the
last legislative session (but did not pass) should be introduced
again and passed if possible. This will permit District groups
to furnish medical care on a group basis.

The contract with the Veterans Administration for care of
men with service connected disabilities should be accepted by
the State Medical Association.

Due to the unfavorable position of organized labor, it is
probable that the Wagner-Murray-Dingell bill is a dead issue
for this year but the members of the State Medical Society
should write personal letters to the senators and congressman
from South Dakota making known their opposition to this bill.

We believe immediate steps should be taken by the com-
ponent district societies to revise their minimum fee schedules.

D. A. Gregory, M.D., Chairman
W. A. Dawley, M.D.

M. W. Larson, M.D.

Committee on Public Health
RESOLUTIONS

Submitted by Chairman of Committee, A. Triolo, M.D.
Whereas, there was passed by the 1945 legislature a bill
known as Senate Bill 62, designated in the Session Laws of
South Dakota, 1945, as An Act Defining and Regulating Hos-
pitals, Maternity Homes, Sanatoriums, Rest Homes, Nursing
Homes, Boarding Homes, and Related Institutions; To Provide
for the Granting, Suspending, and Revoking of Licenses There-
for; to Provide for Penalties for a Violation Thereof; and to
Repeal Chapter 27.12 of the South Dakota Code of 1939. This
bill was passed by both houses almost unanimously, was signed
by Governor Sharpe and received the endorsement of the State
Osteopathic Association at their annual convention in Sioux
Falls in May 1945. Since then, however, petitions based on
false premises were circulated in every county in the state and
received sufficient signatures to satisfy the legal requirements to
enable the Secretary of State to pronounce these petitions valid
and satisfactory for a referendum of the act in question. This
act will therefore appear on a ballot at the general election this
fall and the action of the State Legislature either approved or
rescinded according to the vote, Therefore,

Be it resolved, that the South Dakota State Medical Associa-
tion approves the purpose of this bill and recommends that
the members of the association make every effort to secure its
passage at the next general election.

Whereas, the State Board of Health has been able to secure
funds to purchase and operate mobile units for the purpose of
making a complete survey by mass radiography of the chest
to all in the state who are willing to have such examination
made without cost to the patient, and in every case where any
evidence of a pathological change is noted the patient is referred
to his or her family physician with instructions to have further
examinations made and accept the advice of the family physi-
cian as to whatever treatment is deemed best.

And whereas, this is purely a case-finding effort on the part
of the State Board of Health to locate every person suffering
from pulmonary tuberculosis with a view to the eradication of
the disease as far as it is possible, and in no case does the State
Board of Health assume the functions of the family physician
or those having radiological equipment and expense of the
follow-up of such cases as may be located, Therefore,

Be it resolved, that the South Dakota State Medical Asso-
ciation agrees to sanction this work of the State Board of
Health as above outlined and is confident that the case-finding
work of the State Board of Health is in the interest of the
general public and is in no way derogatory to the private prac-
tice in medicine, surgery, and radiology.

Whereas, a major inadequacy, in the civilian health protec-
tion, exists consequent upon the failure of most counties in the
state to provide even minimum necessary sanitary and other
preventive services for health by full time professionally trained
medical and auxiliary personnel on a merit system basis, sup-
ported by adequate tax funds from local and state, and where
necessary, from federal services. Therefore,

Be it resolved, that the South Dakota State Medical Associa-
tion is willing to use all appropriate resources and influence of
the association to the end that at the earliest possible date com-
plete coverage of the state’s area and population by county or
district full time modern Public Health Service be achieved.
Sub-Committee on Tuberculosis.

We are pleased that during the past year the Attorney Gen-
eral of the state of South Dakota has ruled that patients may
be quarantined at the state sanatorium without any additional
legislation. This gives us a means of compelling patients with

August, 1946

255

active tuberculosis to remain in quarantine, or be subject to
immediate arrest. This does not give anyone the power to com-
pel a patient with an active tuberculosis to enter the sanatorium,
but the Attorney General feels that it is possible to quarantine
them once they have entered the sanatorium. This has had a
definite effect on several patients already. Some who have in-
dicated a desire to return home where they will be a menace,
have reversed their opinion and have agreed to continue isola-
tion. In most instances after becoming acclimated and studying
the situation under calm conditions they have decided that the
wisest course is to remain under isolation. They have appre-
ciated being compelled to remain so that their families would
be protected.

It would be well to review the section of the regulations pub-
lished by the State Board of Health pertaining to quarantine
for tuberculosis. "Regulation No. 22, Section 2, Quarantine.”
Any individual afflicted with tuberculosis of the lungs in a com-
municable form, diagnosed by a licensed physician, as shown by
x-ray or the presence of tubercle bacilli in the sputum, in order
to protect others from becoming infected, may be quarantined
on his premises by the local Board of Health, the Health Offi-
cer on the direction of the State Board of Health, the State
Health Officer, or by the full time Medical Health Officer of
any city or county.

The Attorney General concludes with this statement, "I am,
therefore, of the opinion that patients residing in the state sana-
torium and receiving treatment for tuberculosis may be placed
under quarantine in such institution in the manner and sub-
ject to the provisions of said Board of Health Regulation No.
22.”

It will be appreciated that some cases of tuberculosis of the
lungs are in a non-communicable or inactive form. Such cases
could be allowed to remain at home under proper supervision.
This is particularly true if there are no small children in the
home. In some very few instances it is possible that the patient
will also learn to dispose of his sputum in such a manner that
there is very little danger of infecting others. In such instances,
if the disease is very far advanced, and if there are no children
in the family, living in the home for the short remaining time
could be considered. It is merely desired to control the indi-
vidual who has no regard for the rights of others.

It is the feeling of this committee that additional legislation
is not needed at this time.

During the past year two portable photofluorographic units
have been ordered by the State Board of Health. These units
and the funds to operate them, both supplies and personnel,
have been allocated to South Dakota as a portion of the appro-
priation of the United States Public Health Service. The first
unit ordered was to be a self-contained unit with trailer and
generator. This unit probably will not be delivered until later
in the summer. The second unit is a mobile unit carried in
a station wagon or panel truck. It is necessary to have a source
of power and a room in which to set it up. This unit should
be very valuable for large schools and industries. The second
unit should be in operation about May 1st. It is planned to
cover as much of the state as possible with these units. The
films are to be returned to the sanatorium for developing and
reading. At this time it is planned that the interpretation of
the plate will be carried on by the sanatorium staff. A report
will be forwarded to the State Board of Health at Pierre, and
a report on all positive cases will be sent to the local physician.
This report will merely indicate that some pathology is pres-
ent and that the patient should have a clinical examination
together with a 14"xl7" x-ray. It is requested that the 14"xl7"
plate be returned to the sanatorium for examination so that our
records may be completed.

This committee feels that a very intensive educational program
is necessary in the state. This should be carried on through lay
organizations by some one particularly trained in this field. This
would be of great value preceding the use of the photofluoro-
graphic units in a community.

W. L. Meyer, M.D., Chairman

D. S. Baughman, M.D.

Sub-Committee on Cancer

Due to the fact that the members on this committee are so
far removed from one another, it has been necessary for each

individual to carry on his own campaign and is therefore mak-
ing an individual report of his own.

Dr. Gilbert Cottam is making a report of the public health
work in cancer and I am giving the report for the Field Army
for the American Cancer Society in this state. The report of
Dr. Gilbert Cottam, superintendent of the State Board of
Health, follows:

As a member of the sub-committee on cancer I beg to state
that the efforts of the State Board of Health in cancer control
have been largely directed along educational lines. We have
published in our monthly bulletin, South Dakota Health High-
lights, a series of excellent articles by Dr. J. C. Ohlmacher and
have made frequent reference to the subject in various issues
of the same publication which has a mailing list of approxi-
mately 2,500. We have also shown educational films of cancer
control to various lay groups and have furnished speakers on
the subject whenever requested.

Dr. R. E. Jernstrom recommends the following: (1) That
efforts be made to establish tumor clinics in South Dakota.
(2) That the State Association cooperate as fully as possible
with the South Dakota Field Army of the American Cancer
Society.

The report of the Field Army of the American Cancer So-
ciety was handed to me by the State Commander, Mrs. Lucille
Dory and is as follows: Field Army Report 1946. Ten coun-
ties completely organized as to county organization, financial
and educational. Five counties organized as to financial status,
giving the educational coverage to the county in cooperation
with the use of campaign literature.

School program has been introduced in several schools. Ev-
ery school in Todd county has used the textbook. Other schools
are Deadwood, Lead, Watertown, and Doland.

65,000 pieces of literature have been distributed this year.

Papers by clubwomen, and many talks by doctors and county
commanders have been given.

Every radio station in the state has carried programs on
cancer.

The Field Army News has been sent to every doctor and
dentist in the state, asking that they put the paper on their
reading table so that others may read the work of the field
army.

That the word about cancer is slowly spreading over the state
has been proven by the fact that 63 counties have had contri-
butions from them.

The State Campaign for cancer funds for use in this state
and nationally is now drawing to a close. It must be pointed
out that 60 per cent of all funds donated in this state will
remain here and 40 per cent will go to the national organiza-
tion. The quota set for South Dakota was $25,000. Up to
this time, outside of Sioux Falls, about $12,000 has been con-
tributed. We hope that when the full report comes in that
we will have reached our goal.

I feel that when Mr. George Sexauer, state campaign chair-
man, and Mrs. Lucille Dory have the state completely organ-
ized, that it will be an easy matter to raise any given amount
set up by the national organization in this state. I feel that
the organization should be completed by the time the campaign
for 1947 appears.

It has been suggested by Mr. Sexauer, that a State Cancer
Commission be organized in this state, whose authority it will
be to pass upon the expenditure of all monies in this state.
It is proposed that this commission be composed of five lay-
men and five physicians. It is hereby recommended that the
five physicians be composed of four physicians appointed at
large whose terms of office be From one, two, three and four
years respectively and the state chairman of the Cancer Com-
mittee. The latter to be appointed to this committee as long
as he is chairman of the Cancer Committee. (I bring this up
today for approval by the delegates and councilors of the State
Medical Association.) The names of the other four physicians,
who are to be appointed at large, will be proposed later to the
councilors, who may be approved or rejected.

During the past year a physician has been appointed in every
county in the state to represent the Medical Society, who can
act as advisor to representatives of the Field Army. This phy-
sician is also to act in any educational campaign that may be
put on in his community. In other words, this physician is to
represent the physicians of this state.

256

The Journal Lancet

From the funds obtained from the cancer campaign, there is
to be about $3,500 set aside for sponsoring a refresher course
on cancer at the University of Minnesota in Minneapolis some
time this fall. About fifty physicians who are interested will
be selected to go. All expenses will be paid for about a three-
day course.

We have recently sent out a questionnaire to all the physi-
cians in this state to determine: (1) Their interest in a re-
fresher course. (2) Whether they would like to have question-
able cancer cases sent to them for examination. (3) Whether
they would like to treat cancer cases. (4) Whether they would
like to treat cancer cases, surgically, radiologically, or roentgeno-
logically. (5) Whether they were interested in cancer or not.

The results of this survey are herein submitted.

O. S. Randall, M.D., Chairman
* * *

As a member of the sub-committee on cancer I beg to state
that the efforts of the State Board of Health in Cancer Control
have been largely directed along educational lines. We have
published in our monthly bulletin, South Dakota Health High-
lights, a series of excellent articles by Dr. J. C. Ohlmacher and
have made frequent references to the subject in various issues
of the same publication, which has a mailing list of approxi-
mately 2,500. We have also shown educational films of Cancer
Control to various lay groups and have furnished speakers on
the subject whenever requested.

The provision made by the legislature at its last biennial ses-
sion for inauguration of the four medical years courses in the
State University may possibly lead to the creation of a center
for the study and control of cancer on a basis much more ex-
tensive than has heretofore been possible. To attempt to form
an independent center for this purpose in a small state like ours
would be entirely too expensive and impracticable to warrant
serious consideration.

Gilbert Cottam, M.D., Superintendent,

State Board of Health

Sub-Committee on Syphilis Control Program

During the past year the State Board of Health has contin-
ued its chemical control plan for control of venereal diseases.
This provides for payments to physicians for reports of treat-
ment given to patients with early or potentially communicable
syphilis and to patients with gonorrhea when laboratory reports
indicate that a cure has been effected.

A new program which was added during the past year pro-
vides for the hospitalization and rapid treatment with penicillin
of early cases of syphilis. Under this plan the State Board of
Health furnishes the necessary drugs for treatment and pays
the hospital on a prearranged fee schedule. The physician’s fee
is paid by the patients.

During the coming year it is anticipated that changes will be
made in the V.D. control plan to bring it up to date with mod-
ern treatment methods particularly as regards the use of peni-
cillin in treatment.

Gilbert Cottam, M.D., Chairman

Committee on Necrology

I have been unable to secure any additional information con-
cerning the deaths of doctors in the state, excepting what was

furnished me by letter April 4th, as follows:

H. H. Aldrich, DeSmet 6-16-45

R. V. Overton, Winner 6-20-45

Chas. J. Lavery, Aberdeen 7-6-45

Guy Ramsey, Sioux Falls 8-19-45

F. W. Minty, Rapid City 11-25-45

G. H. Stidworthy, Viborg 1-29-46

Walter L. Vercoe, Hot Springs 1-30-46

Joseph H. Holleman, Springfield 2-19-46

A. E. Bostrom, DeSmet 3-26-46

I wish some system could be established whereby reports of
deaths with certain obituary data could be assembled during
the year and not have the whole matter delayed until the ap-
proaching date of our state meeting. It seems to me the vari-
ous district secertaries should take care of this matter from
their districts.

J. A. Hohf, M.D., Chairman

Committee on Medical Benevolence
The committee on Medical Benevolence desires to submit the
following report for 1945-46:

Assets, June 1, 1946:

Cash on Hand (Savings, etc.) . .. $ 246.87

Series F Bonds (cost value) 1,264.17

From S. D. State Medical Assn, and

Auxiliary Units ... 157.50

Interest on Savings 4.60

Total $1,673.14

Suggestions: (1) That the State Medical Association con-
tinue to contribute 50c per member per year. (2) That the
Auxiliary become more active in their participation.

W. H. Saxton, M.D., Chairman
C. E. Sherwood, M.D.

Geo. Stevens, M.D.

Committee on Scientific Work

Our Committee respectfully submits to the House of Dele-
gates the scientific program of the 1946 annual session as evi-
dence of its activity.

William Duncan, M.D., Chairman

F. S. Howe, M.D.

R. G. Mayer, M.D.

SCIENTIFIC PROGRAM
Monday, June 3, 1946

9:00 AM. Office Practice of Gynecology — Leonard A.
Lang, M.D., Minneapolis, Minn. Clinical Assistant Professor
of Obstetrics and Gynecology, University of Minnesota Medical
School, and Chief of Service, Obstetrics and Gynecology, Min-
neapolis General Hospital.

9:45 Complications in Bilateral Congenital Polycystic Dis-
ease of the Kidney — T. P. Grauer, M.D., Chicago, 111. Asso-
ciate Professor of Urology, Northwestern University Medical
School.

10:30 Intermission. Motion pictures. Medical and technical
exhibits.

11:00 The Importance of Some Remedial Aspects of Heart
Disease — N. C. Gilbert, M.D., Chicago, 111. Professor of
Medicine, Northwestern University Medical School.

12:00 Lunch.

1:30 P.M. The Pathology of the Retinopathy of Chronic
Glomerulonephritis and Hypertension — Walter C. Camp,
M.D., Minneapolis, Minn. Assistant Professor of Ophthal-
mology, University of Minnesota Medical School.

2:15 Acute Cholecystitis — Alton Ochsner, M.D., New Or-
leans, La. William Henderson Professor of Surgery and Di-
rector of Department of Surgery, Tulane University Medical
School; Director of Division of General Surgery, Ochsner
Clinic.

3:00 Intermission. Motion pictures. Medical and technical
exhibits.

3:30 Bulbar Type Acute Poliomyelitis; Diagnosis and Treat-
ment— J. Harry Murphy, M.D., F.A.A.P., Omaha, Neb.
Associate Professor of Pediatrics, Creighton University Med-
ical School.

4:15 Clinical Aspects of Chemotherapy — Wendell H. Hall,
M.D., Minneapolis, Minn. Clinical Instructor in Medicine,
University of Minnesota Medical School.

7:00 Annual Banquet. A Report on Activities of the Coun-
cil on Medical Service and Public Relations and the Associated
Medical Care Plans — A. W. Adson, M.D., Mayo Clinic, Ro-
chester, Minn. Member of the Council on Medical Service and
Public Relations, American Medical Association.

Tuesday, June 4, 1946

9:00 A.M. — Public Health and Organized Medicine — Arthur
B. Price, M.D., Kansas City, Mo. Senior Surgeon, U.S.P.H.S.,
District Office.

9:30 Psychosomatic Medicine — Gordon R. Kamman, M.D.,
St. Paul, Minn. Assistant Clinical Professor of Nervous and
Mental Diseases, University of Minnesota Medical School.

10:00 A Few Essentials in Prescribing Physical Medicine
in General Practice — Earl C. Elkins, M.D., Rochester, Minn.
Consultant in Section on Physical Medicine, Mayo Clinic.

10:30 Intermission. Motion pictures. Medical and technical
exhibits.

August, 1946

257

11:00 Modern Concepts of Hypertension — • Kenneth G.
Kohlstaedt, M.D., Indianapolis, Ind. Director of Lilly Labora-
tory for Clinical Research, Indianapolis City Hospital.

11:30 Management of Breech Delivery — Leonard A. Lang,
M.D., Minneapolis, Minn. Clinical Assistant Professor of
Obstetrics and Gynecology, University of Minnesota Medical
School, and Chief of Service, Obstetrics and Gynecology, Min-
neapolis General Hospital.

12:00 Lunch (Alonzo Ward Hotel). Round Table Dis-
cussion of X-Ray Films — N. J. Nessa, M.D., Sioux Falls, pre-
siding; P. V. McCarthy, M.D., Aberdeen, leader.

1:30 P.M. The Diagnosis, Treatment and Prognosis of
Cases of Carcinoma of the Gastrointestinal Tract. (1) Surgical
Considerations — Alton Ochsner, M.D., New Orleans, La.
William Henderson Professor of Surgery and Director of De-
partment of Surgery, Tulane University Medical School; Di-
rectors of Division of General Surgery, Ochsner Clinic. (2)
Gross and Microscopic Pathology — J. R. McDonald, M.D.,
Rochester, Minn. Head of Section of Surgical Pathology,
Mayo Clinic; Associate Professor of Pathology, Mayo Founda-
tion Graduate School, University of Minnesota. (3) Thera-
peutic Radiology — H. H. Bowing, M.D., Rochester, Minn.
Section on Therapeutic Radiology, Mayo Clinic, and Professor
of Radiology, Mayo Foundation Graduate School, University
of Minnesota.

3:45 The Purpose and Methods of the American Cancer
Society — A. W. Oughterson, M.D., New York, N. Y. Med-
ical and Scientific Director, American Cancer Society.

* * *

South Dakota Academy of Ophthalmology and Otolaryngology
President — J. A. Nelson, M.D., Sioux Falls
Vice President — P. G. Bunker, M.D., Aberdeen
Secretary-Treasurer- — J. D. Alway, M.D., Aberdeen
SCIENTIFIC PROGRAM (Band Room, Civic Arena)
Monday, June 3, 1946

10:00 A M. Clinical and Pathological Study of Uveitis —
Walter E. Camp, M.D., Assistant Professor of Ophthalmology,
University of Minnesota Medical School, Minneapolis, Minn.

11:00 Diverticula of the Pharynx (Report of 20 Cases) —
Kenneth A. Phelps, M.D., Assistant Professor of Otology,
Rhinology and Laryngology, University of Minnesota Medical
School, Minneapolis, Minn.

SPECIAL COMMITTEES
Radio Committee

There has been some progress. Rapid City and Sioux Falls
have been having broadcasts of medical subjects. In Rapid City
there has been difficulty in maintaining a continuous weekly
program, due both to your chairman and lack of cooperation
from the station. There will be an attempt made to correct this.

R. E. Jernstrom, M.D., Chairman

Committee on Publications

The contract with the Journal Lancet as official publica-
tion of the South Dakota State Medical Association still has
two years to run. The suggestion is made that publication of
a monthly or bi-monthly bulletin of the state medical associa-
tion be considered.

R. G. Mayer, M.D., Chairman

Editorial Committee

It has not been possible for the members of this committee to
meet in person. However, the work of this committee has been
taken care of in the usual manner as evidenced by the Journal
Lancet, which is the official journal of the Association and
which you all receive.

D. S. Baughman, M.D., Chairman

Committee on Education and Hospitals

The following work is now on the road to accomplishment:

L Plans for the development of a four-year school in connec-
tion with the McKennan and Sioux Valley Hospitals at Sioux
Falls are proceeding.

2. The acquisition of experienced, well-known clinical teach-
ers to head major departments is being carried on as rapidly as
possible. It now seems assured that we shall be able to procure
full-time clinical teachers to head the three major departments.

3. At this time it appears unlikely that we shall be able to
start junior-year instruction the coming fall.

4. We shall proceed, nevertheless, toward the organization of
the clinical staff, the development of curriculum, and the estab-
lishment of an out-patient department.

5. We are proceeding towards the further development of
our present basic science school. The acquisition of outstanding
men to head departments made vacant by the resignation of
interim appointees assumes some difficulties, largely because of
the lack of housing facilities in Vermillion. Married men,
especially men with families, though otherwise willing to become
associated with us, hesitate to come unless they can be assured
of proper accommodations.

6. During the last month several outstanding clinicians and
one outstanding school administrator have visited our school and
the hospitals in Yankton and Sioux Falls and have expressed
themselves as confident that we can develop a good, small,
accreditable four-year school in South Dakota. They also
sensed the need of such development.

E. M. Stansbury, M.D., Chairman

Committee on Spafford Memorial Fund

I am reporting on the Dr. Frederick Angier Spafford Mem-
orial Prize. This prize was established by the South Dakota
State Medical Association and other friends of Dr. Spafford in
recognition of his many years of service as a member of the
State Board of Regents of Education and especially his interest
in the study of the ancient classics. It consists of the interest
on $1,000 and will be awarded to that student who, in the
opinion of the committee, has made most satisfactory progress
in the study of Latin, preferably but not necessarily Virgil,
during the current school year. This year the prize amounted
to $25.00 and was awarded to Miss Imogene Hooshagen of
Sioux Falls, S. D.

J. C. Ohlmacher, M.D., Dean

Committee on Military Affairs

On behalf of the Military Affairs Committee I wish to sub-
mit the following report:

From the 1st district there were eight medical men in service,
all of whom have returned to private practice.

From the 3rd district there was one member in the service
and he has returned to private practice.

In the 4th district there were four in service; two are still in
service, two discharged, one returned to his former location and
one whose whereabouts are unknown.

Of the two from the 5th district one is still in service and
the other is back in private practice.

From the 6th district there were six members in the Armed
Forces, all of whom have returned to their former locations.

The 8th district had eight members in service, all of whom
are now discharged. Four are back to their former locations
and four are elsewhere.

From the 9th district there were sixteen men in the Armed
Forces. Of these, twelve have returned to their former locations
and the whereabouts of the other four are unknown.

There was one member who served from the 12th district
and he is back to private practice.

Of the districts not reporting there are approximately twenty-
three medical men who have served with the Armed Forces.
One of these is still in service, and the location of others is
unknown.

There was a total of 67 men in Service with three still active.

J. C. Smiley, M.D., Chairman

Committee on Radiology

The Committee on Radiology begs to report that no essential
change has developed in the practice of our specialty during the
past year. The therapeutic value of irradiation is well recog-
nized by our profession and lay people in general. Our tumor
patients are being referred and treated with less delay and loss
of time which means better prognosis and end results.

We again reiterate that Radiology does not favor application
of the science by hospital and insurance plans without trained
medical supervision whenever possible.

N. J. Nessa, M.D., Chairman
B. C. Murdy, M.D.

J. H. Lloyd, M.D.

258

The Journal Lancet

Committee on Medical Service and Public Relations

The Committee on Medical Service and Public Relations re-
ports as follows:

Much is being said in our press, radio and legislative halls
these days on health insurance in the United States with which
you are all familiar.

Advocates of compulsory health insurance argue on the basis
of humanitarianism with medical service for everybody. The
majority of the medical fraternity argue that they can do the
same job better and cheaper by themselves than by a govern-
ment bureaucracy.

We believe that compulsory health insurance will lead to
lower medical standards and efficiency and thereby the public
clientele will suffer in proportion.

We are fully in accord with pending proposals by organized
medicine and hope for its final success over pending political
legislation.

N. J. Nessa, M.D., Chairman

T. F. Riggs, M.D.

G. W. Mills, M.D.

Committee on Prepayment and Insurance Plans

During the past year your committee has followed closely the
initiation and development of plans to prepay medical and hos-
pital costs in various sectors of the country. Members of your
committee have attended meetings at St. Paul, Minneapolis,
St. Louis, and Chicago, all dealing with economic problems of
medical practice.

This report will call your attention to certain significant facts
and developments in this field during the past year. Details of
necessity must be left out but if you have read the material
which has come to your desks throughout the past year you
are already familiar with much of it.

First, we must recognize that the public demands and will
get prepayment of medical and hospital care by one means or
another. If voluntary plans are not available or inadequate,
this will be accomplished very soon by some form of political
medicine.

In recognizing these facts the A.M.A. at its last meeting
took an unprecedented step. It instructed its Committee on
Medical Service and Public Relations to develop a National
Prepayment Health program, to coordinate all existing plans
and to stimulate the formation of new ones in areas where none
exist at present.

We, in South Dakota, fall in the last category, namely, an
area where no medical prepayment plan now exists. It will be
recalled that we failed in our attempt to have an Enabling Act
for this purpose passed by the last session of our State Legis-
lature. Likewise, the State Hospital Association failed in its
attempt to obtain a satisfactory Enabling Act permitting the
development of the Blue Cross Hospital Plan in South Dakota.
We are now one of the few states in the union where nothing
tangible has been accomplished to enable the average individual
to prepay medical, surgical and hospital costs.

The committee feels that one of two courses of action is open
and should be followed as promptly as possible. First, we can
again attempt to accomplish what we failed in at the last legis-
lative session. Any such effort must be attended by more in-
terest, cooperation and work on the part of the doctors of the
State than was evidenced in 1945. The passage of such legisla-
tion would be aimed at the establishment of a non-profit cor-
poration to supply medical and surgical care to the public. Of
necessity the success of this plan would depend also on coopera-
tion with and development of the Blue Cross Hospital Plan in
this State. Thus, it would mean that the medical profession
must actively support the State Hospital Association in their
attempt to procure workable enabling legislation.

Our second approach to the problem lies in cooperation with
the insurance underwriters of the state to develop something
similar to what is known as "The Wisconsin Plan.” In this
plan those commercial companies writing insurance in the state
of Wisconsin have agreed to write a standard policy approved
by the Wisconsin Medical Association as to premium provi-
sion and benefits. The physician in Wisconsin may agree to
cooperate with the plan by accepting the schedule of benefits
as full payment in beneficiaries who have annual income of
$2080 without dependents or $2600 with dependents. In cases
where annual income is higher cash benefits will be paid and

the physician will be permitted to charge a higher rate than the
policy fee schedule. This plan gives:

(a) Full coverage benefits for care involved in the
fields of surgery and obstetrics, whether given in or
out of a hospital;

(b) Full coverage benefits for anesthesia and radi-
ology, when given outside of a hospital;

The obvious benefits of the Wisconsin Plan to the medical
profession and the public are:

1. The doctors need not enter a new field, the field
of insurance.

2. The doctors can cooperate wholeheartedly with
the insurance men to bring increasingly adequate cov-
erage to a large group of our population who need
and desire reasonably priced and financially sound
prepayment insurance.

If we, in South Dakota, could develop something similar to
the Wisconsin Plan it would seem more suited to our situation
than the initiation of an insurance organization and plan of
our own.

Hearings on the Wagner-Murray-Dingell Bill are now going
on in Washington. The matter of prepaying medical and hos-
pital expense is being brought rapidly into the foreground of
public thinking. The committee feels that the House of Dele-
gates at its annual meeting should spend adequate time for
thorough discussion of this problem. If time for conclusive
discussion is not available and if action by the House of Dele-
gates is necessary to commit this body to one plan or another,
this committee recommends that a special meeting of the House
of Delegates be called at an early date to consider this matter
solely.

After serious consideration and study of this problem in
other areas it is the recommendation of this committee that
South Dakota’s needs can be served best by a program similar
to that in effect in Wisconsin. If a special meeting is called for
this purpose, we suggest that representatives of interested in-
surance organizations be invited to meet with us for a careful
discussion of the problem.

We, in South Dakota, have had good reason to proceed
slowly and with caution. Our total population is small, our
state is largely rural in character, and we have but a small
percentage of our population engaged in industry. Your com-
mittee feels, however, that much ground work in other areas
has been done proving that certain plans are feasible and suc-
cessful. It is our opinion that definite steps are necessary
promptly to give the South Dakota people what they want and
need to protect them and ourselves from the fate of political
medicine and to cooperate with the A.M.A. program and our
colleagues in the other forty-seven states.

H. R. Brown, M.D., Chairman

Advisory to Departments of State Board of Health

Committee on Orthopedics

The following is a report of the work done by the Crippled
Children’s Department of the State Board of Health, which
was supplied by Dr. Triolo, for the period of January 1, 1945,
through December 31, 1945:

Children on State Register January 1, 1945 2,108

New cases placed on Register during year 262

Total on Register at end of year 2,370

Cases removed from Register during year 146

Crippling condition cured 9

Reached age of 21 115

Removed from State 15

Death 7

Total on Register at end of year 2,224

Number of Clinics held 8

Admission to clinics 388

Visits direct to Orthopedists office in lieu of clinics 171

Total clinic and office visits 559

HOSPITAL CARE

Children under care in hospitals January 1, 1945 27

Children admitted to hospitals during year 166

(130 new cases and 36 previously under care)

Total

193

August, 1946

259

Discharges — 182

Children under care December 31, 1945 11

Total days hospital care provided during year 6,955

Guy E. Van Demark, M.D., Chairman
W. H. Karlins, M.D.

F. W. Minty, M.D. (deceased)

Committee for Study of Reasons for Rejection
of Selectees in South Dakota

This is a preliminary report on the analysis of physical exam-

inations of selective service registrants during wartime in South
Dakota, April 1942 to March 1943.

Percent of Registrants in Each Age Group
Found to Have No Defects

Age 18 to 44 - — ----- 18.3

18 to 24 - 24.6

25 to 29 — 19.5

30 to 37 - 13.6

38 and over 5.6

Rejection Rates per 1,000 Registrants.

Ten Leading Causes

1. Mental Disease 45.6

2. Musculo-Skeletal 44.8

3. Cardio- Vascular 43.4

4. Hernia _ — 43.4

5. Eye 35.9

6. Neurologica 1 26.2

7. Ear _ 18.6

8. Tuberculosis 10.5

9. Syphilis „ 9.7

10. Educational deficiency 4.8

Mental Disease-. Major disorders include psychoneurotic dis-
orders, psychopathic personality and grave mental or person-
ality disorders.

Musculo-Skeletal Disorders: For the most part these were dis-
qualifying disabilities resulting from injuries such as limita-
tion of motion of a joint and deformities resulting from frac-
tures (hands, knees and elbows were most frequently af-
fected) . Amputations ranked second and spinal malforma-
tion (kyphosis, scoliosis, and lordosis) ranked third.
Cardio-Vascular Disease: Mostly hypertension and valvular

heart disease.

Hernia: Inguinal type was most prominent.

Eye: Diseases of cornea and retina; cataracts.

Neurological: Epilepsy; post-traumatic syndromes; residual of

poliomyelitis.

Ear: Otitis media; severely defective hearing.

A. Triolo, M.D., Chairman

Committee on Medical School at the University
of South Dakota

This Committee has not functioned as an entity, merely as
a part of the Council.

In the past year we have had two interviews in the Council
with President Weeks of the University of South Dakota, and
Dr. J. C. Ohlmacher, Dean of the Medical School of the Uni-
versity of South Dakota.

At present there is an established accredited Class A, two
year medical school in operation, which has been the case for
several years. The Legislature has appropriated $70,000 for
the purpose of expanding the school into a four year institu-
tion.

There has been considerable progress made along this line.
A full time Professor of Surgery, Professor of Medicine, and
Professor of Eye, Ear, Nose and Throat have been secured,
all men eminent in the profession and well qualified for the
position.

An arrangement has been tentatively made with the Sioux
Falls hospitals to be used for teaching purposes. It will prob-
ably be necessary that a building be secured or erected in Sioux
Falls for an Out-Patient department for teaching purposes.
There is no doubt that the Veterans Bureau will establish a
good sized hospital in Sioux Falls providing the medical school
set up goes through, otherwise it is very doubtful if they will
assign any of the new hospitals to that region, this being their
present national policy.

It is going to be very difficult to have the school established

and operating in Sioux Falls this September, although this is
the University’s present plan.

The Council of the South Dakota State Medical Association
has been very dubious of the possibility of establishing a first
rate Class A medical school in South Dakota. The Council
has gone on record as being opposed to the establishment of
any school except one that can qualify as Class A.

It is understood that the University’s advice on the estab-
lishment of the school comes from the Association of Medical
Colleges, whose secretary has been up here and has made a
tour of the state and spoken before a number of the district
societies.

At the last meeting of the Council on April 14, 1946, at
Huron, the Council voted that the President of the University
invite Dr. Victor Johnson of Chicago, Secretary of the Com-
mittee on Hospitals and Medical Education of the American
Medical Association, to visit the University and to sit in on
the present plans for establishing a four year school. Since the
approval of the American Medical Association is necessary to
have a Class A school, it is felt that this will help to insure
the establishment of such a school in South Dakota.

C. E. Robbins, M.D., Chairman

Committee on National Legislation

Without question the most important piece of national legis-
lation, as far as the medical profession is concerned, ever intro-
duced in Congress, is the present Wagner-Murray-Dingell bill.

Assuming that all members are familiar with it, nothing fur-
ther will be said about its contents or purpose.

To our knowledge the House of Delegates has never offi-
cially gone on record as being opposed to this bill, consequently
it is recommended that such action be taken during this session.
This will enable the President to file a statement with the Sen-
ate Committee on Education and Labor opposing this bill with
the support of the State Association. Doctor Howe, President-
Elect, has already filed such a statement.

During the past year some of the members of this committee
have attended several meetings which concerned compulsory
health insurance either directly or otherwise. Further mention
of these meetings is contained in the reports of the officers and
other committees.

Through correspondence carried on by Doctor Pankow and
the chairman of this committee word has been received from
both of our Senators and both of our Congressmen to the
effect that they are all definitely opposed to the Wagner-Mur-
ray-Dingell bill. Furthermore, considerable effort" has been
made to reach the public through the medium of speaking to
lay groups and encouraging the distribution of literature which
is supplied without charge by the National Physicians Com-
mittee.

As it is now apparent that the National Physicians Com-
mittee is by far the most effective of all the organizations
attempting to mold public and legislative opinion in the field
of medical care this committee recommends the following:

1. That the State Association pass a resolution en-
dorsing the National Physicians Committee.

2. That every member be urged to give the Na-
tional Physicians Committee financial support.

3. That the State Committee on National Legisla-
tion be authorized to co-operate with the National
Physicians Committee and to become, in effect, a com-
ponent state committee of the national organization.

4. That this committee carry on its activities, in-
sofar as possible, according to the recommendations
made by the National Physicians Committee in its in-
formational bulletin No. 2, issued February 14, 1946.

Probably next in importance to compulsory health insurance
legislation is the Hill-Burton hospital bill. This has passed the
Senate and is now being considered by the House of Repre-
sentatives. It is definitely a constructive piece of legislation and
has the full endorsement and support of both the American
Medical Association and National Physicians Committee, con-
sequently, it is recommended that the State Association pass
a resolution to the same effect. Furthermore, all members are
urged to write to their Congressman requesting them to vote
for this bill.

In addition to the above, there have been several other bills
introduced in Congress which would in some way or another
affect medical care and the practice of medicine.

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The osteopaths and chiropractors apparently are quite active
in Washington also, judging by their numerous attempts to
attain by legislation, privileges to which they are not entitled
by educational qualification.

On numerous occasions, and usually at the request of Doctor
Joseph Lawrence, director of the American Medical Associa-
tion’s Washington office, your officers have sent letters and tele-
grams to our Senators and Representatives urging them to
help defeat this type of legislation.

Through no fault of organized medicine, and largely because
of expediency, osteopaths were included in the bill which estab-
lishes a new department of medicine and surgery in the Vet-
erans Administration. In other words the Veterans Adminis-
tration may hire them, but the language of the bill does not
make this mandatory. What effect this will have on their new
hospital set-up no one can tell at this early date, however it
is certainly regrettable that this happened.

In conclusion our committee urges everyone to acquaint him-
self with the newly introduced Taft-Smith-Ball National
Health bill. This may possibly be another very effective means
to defeat compulsory health insurance.

The Committee:

William Duncan, M.D., Chairman

R. G. Mayer, M.D.

F. S. Howe, M.D.

H. R. Brown, M.D.

C. E. Robbins, M.D.

Committee on Rural Medical Service

The health problem that South Dakota faces at the present
time is that of having a population of one-half million, scat-
tered over a very large area. Some of our largest counties have
the smallest population and in many of these counties there
are no doctors. In the state there are 342 licensed practicing
doctors, 114 of whom are 65 years of age. Ninety per cent
of the doctors are now concentrated in larger centers of pop-
ulation. In South Dakota that would be cities of 1,000 and up.
In the centers of larger population, there is a doctor for every
800 people, while in the rural areas there is one doctor for
every 2,600.

At the meeting of the A M. A., Farm Bureau, Grange and
Farmer’s Union, and other farm organizations at Chicago, on
March 29, 1946, these were some of the chief points brought
out by some of the farm groups:

1. They wanted medical care brought closer to the
farmer by practicing physicians.

2. Hospitals or diagnostic centers closer to the
farmers.

3. Abolition of the $1.00 a mile scale of charging
fees.

4. F.S.A. was universally a flop.

Points brought out by the representatives of the Great Plains
states, Texas, Oklahom, Kansas, Nebraska, North Dakota and
South Dakota:

1. Medical centers will grow in the natural trade
centers, not county divisions. A great deal of stress
has been made by statisticians that there are a certain
number of counties in the United States without any
physician whatsoever. However, if this was given close
scrutiny, it would be found that there were very few,
if any, people living in those counties which have no
doctors. It naturally does not stand to reason that a
doctor should be in a place where he can not be sup-
ported, any more than any other professions or trade
would go to these sparsely populated areas to start up
a business. It was unanimously felt that 30 or 40
miles of modern roads and transportation was not a
hardship.

2. Modern trend of specialization and classification
of physicians in the various boards has inherent trends
to concentrate medical men in centers of large popu-
lation. They felt that better medical service could be
rendered to the public at large if this were true.

3. A doctor has a right to choose where he wishes
to locate and raise his family and give them cultural
advantages and they prefer settling in larger cities
where these things are available.

4. If practicing is more attractive in rural areas as

to income and facilities for work and usefulness, it
will naturally attract and support doctors.

A proposed program for action of state rural health com-
mittees was drawn up as follows:

What should the State Committee on Rural Medical Service
undertake? Meet with interested farm groups such as the Farm
Bureau, Grange, and Farmers Union, and agree on objectives
for common effort. Three types of activity may be considered:

1. Hill-Burton bill. See that sound judgment is exercised in
placing of facilities and other details applying to rural areas.

(a) Insistence on and devising methods for mainte-
nance of high professional standards in all facilities
constructed so that more service will not mean service
of lower quality.

(b) Deciding what constitutes the unit to be served
by various types of facilities, number of people, dis-
tance the sick can be transported, desirability of a
public ambulance service. The present available pro-
fessional personnel and possibility of attracting more.

(c) Deciding what is meant by diagnostic centers
and health centers and their relation to the hospital
as they should apply in each state.

(d) Close affiliation with agencies of state govern-
ment created to administer the Hill-Burton bill or
like legislation.

2. Extending to country people the benetfis of prepayment
plans for catastrophic illness and hospitalization, with special
plans for marginal farmers who may be in part medically in-
digent, but should be encouraged to pull their pound.

3. Promotion of health education among farm people. Initia-
tive here must reside in organized farm groups: Parent-Teach-
ers, 4H Clubs, Home Economics, Boys Camps, Extension de-
partments of State Agricultural Schools, accident prevention and
first aid, sponsoring proper kind of publicity in farm press, and
local papers and local radio.

4. Conference of rural and health leaders sponsored by State
Colleges of Agriculture. Ohio University is a good example.

In areas of smaller population it is impossible to set up a
medical unit of specialists and expect them to be supported.
There was a time when a practicing physician, as a general prac-
titioner, was able to practice a fairly adequate and appreciated
type of service to the community which he served. I still feel
that this can be done. But, with the present trend of educa-
tion for our medical students and graduates, one is led to be-
lieve that medicine cannot be properly practiced unless it is
done by specialists and that a general practitioner is a physi-
cian of less caliber, and consequently has had to go to the rural
communities. I still feel that an alert general practitioner has
a great place in South Dakota, and has at his command the
right to practice medicine unrestricted, as a medical man would
be in the larger centers. He, therefore, must equip himself,
both mentally and with facilities to practice medicine, to carry
out whatever is necessary to the problem which presents itself.
It is a great challenge. He will want to do his best when he
finds that he does not have someone else to make his decisions
for him and to do his work for him. If we, as general prac-
titioners, do not take this challenge, this state will naturally be
a haven for osteopaths and chiropractors who are willing to go
to the smaller centers, and do what they can to bring medical
care to these people who have been forsaken by the medical
profession.

May I add that building medical centers and hospitals
throughout the state is not going to solve the problem. We,
at the present time, are not able to staff what hospitals we have
in the state, due to the shortage of nurses and strikes. We
are not going to be able to build medical centers for diagnosis
or other hospitals until the strikes are over and we get ma-
terials to build them with. In South Dakota we must get this
bill through for a hospital licensure before we can expect to
have any aid from the Hill-Burton act. Prepayment plans
must be looked into. However, these would only do good in
years of prosperity and even at that we have people who would
rather pay their way, both in years of prosperity and years of
depression, rather than subscribe to prepayment plans, which
promise a great deal, but which often don’t pay what the client
expected. Alonzo P. Peeke, M.D., Chairman

M. M. Morrissey, M.D.

C. M. Kershner, M.D.

August, 1946

ADDRESS OF THE PRESIDENT

William Duncan, M.D.
Webster, South Dakota

261

Probably at no time in the sixty-five years since this
Association was founded have there been so many im-
portant problems confronting it as there are today.
Without much question the compulsory health insur-
ance bill now before Congress is the most important of
these. Although we must admit that the proponents of
this legislation have a noble purpose and one which we
share with them, namely, better medical care for all the
people, the methods by which they hope to attain this
goal should be for the most part objectionable to us.
No attempt will be made to discuss this subject fully,
for that has already been done and printed in our jour-
nals many times by men better qualified to do so, and
it would be difficult to add anything new to what already
has been said by them.

I would like, however, to point out a few of the most
objectionable features of the Wagner-Murray-Dingell
bill. First of all, it is compulsory; the people will be
compelled to pay the tax and physicians will be com-
pelled to take part in it, even though the bill as written
does not say so. However, physicians will still be com-
pelled to make a living and when 135,000,000 people
are covered by this insurance it is obvious that we will
have but one choice.

Furthermore, there is hardly a shred of evidence that
enactment of this bill will produce better medical care
for the people. Experience in foreign countries which
have had socialized medicine for many years does not
show this to be the case, and under our present system
this nation is the healthiest of all the larger nations in
the world.

The cost of this program would be tremendous. Ac-
cording to a recent study by E. W. Wilson published in
Barron’s National Business and Financial Weekly, the
total annual cost of social insurance (of which compul-
sory health insurance would be a large part) would be
somewhere between one-seventh and one-sixth of the an-
nual payroll, or 10 to 12 billion dollars, using the aver-
age figures for the past ten years or so. Foreign experi-
ence definitely indicates that no sound economy can bear
such a cost and still maintain the momentum of private
incentive and enterprise.

In addition, the bill is un-American not only in prin-
ciple, but perhaps in origin also. States’ rights would be
interfered with, the private practice of medicine as we
know it today would be destroyed, physicians would lose
their professional independence, and we would all be
regimented under a veritable dictatorship headed by the
Federal Social Security Administrator.

This may sound like an exaggeration but such is the
considered opinion of high-standing medical men who
have studied this bill thoroughly.

Now, assuming that we do not want socialized medi-
cine, what can we do to prevent it? First of all, it would
be well for us to recognize that there is a problem con-
cerning adequate medical care. Then we should go
ahead with constructive measures to solve it.

As far as South Dakota is concerned the overall short-
age of physicians and hospital facilities is our greatest
difficulty. The Hill-Burton bill, which has the endorse-
ment and support of the American Medical Association,
should go a long way toward taking care of the hospital
situation. A solution for the lack of physicians will prob-
ably not be so simple. An approved four-year medical
school in South Dakota would certainly be a big step
in the right direction — even though that alone would be
no guarantee that the graduates of such a school would
locate in the smaller communities where the need is the
greatest. Such a school is now in the process of develop-
ment but is still far from being an actuality, and there
are sound reasons for expressing doubt as to whether
it will receive approval from the American Medical
Association’s Council on Medical Education and Hos-
pitals, and without such approval we would be much
worse off than having no school at all. In order to
clarify this statement, I quote Doctor Victor Johnson,
Secretary of the American Medical Association Council
on Medical Education and Hospitals, in his last annual
report on medical education.

"Unfortunately, some of the current proposals for establish-
ing new medical schoods are ill conceived and rest on a failure
to understand certain well recognized principles which must
guide the thinking about such projects. Some of these consid-
erations, which would seem to be axiomatic, but too often dis-
regarded, are as follows:

1. There is no justification for the establishment of a med-
ical school to meet such an acute temporary emergency as the
absence of physicians on military duty.

2. Any overall increased present or postwar need for addi-
tional physicians occasioned by the war can be provided by ex-
isting approved schools. There is no justification for establish-
ing new medical schools for this purpose. Furthermore, the
normal annual number of graduates from existing schools is
adequate for the peacetime needs of the country, granted dis-
tribution is equitable.

3. The maldistribution of physicians as between the states or
between urban centers and rural areas is a problem to be at-
tacked primarily by other means than the production of more
doctors in a given state; the rate of production and the distri-
bution of doctors in this country are independent.

4. Medical education is by far the most expensive form of
professional training, requiring an initial outlay and subsequent
annual budgets in the early years totaling millions of dollars
and not tens or hundreds of thousands. A school whose re-
sources include annual budgets of less than $350,000, inde-
pendent of the cost of maintenance of the hospital and out-
patient departments, is unlikely to conduct a satisfactory pro-
gram.

5. The operation of an acceptable four year medical school is
far more expensive than the conduct of a basic science medical
program.

6. The trend toward more full time clinical instructors is so
general that any school commencing with all or nearly all of its
staff on a part time basis is already obsolete.

7. The possession of the M.D. degree and the successful
practice of medicine do not, in themselves, indicate that a phy-
sician is qualified to teach medical students satisfactorily, even
in clinical subjects. Volunteer and part time teachers require
special training and experience.

8. A hospital well equipped to provide medical care to the
people or even satisfactory for internship or residency training
is not thereby necessarily satisfactory as a medical school hos-
pital.

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The Journal Lancet

9. Medical schools must be so located that there is an ample
supply of patients of all kinds, on the one hand, and competent
instructors, including specialists, on the other hand.

10. No medical school is worthy of the name which does not
carry out some significant research, even though the primary
aim of the school is the training of general practitioners.

A failure to observe these generalizations might lead to costly
ventures without prospects of accomplishing the ends sought,
however desirable those ends may be.” — (J.A.M.A., Sept. 1,
1945, pp. 45 and 48.)

In view of such statements by the spokesman for this
Council, I believe that this Association should do two
things. First, it should take immediate steps to secure
at least an opinion from him regarding the prospects of
South Dakota’s four-year school receiving the Council’s
approval. Second, it should carry out a thorough inves-
tigation to find out whether or not South Dakota stu-
dents can still receive a medical education in established
schools outside of the state.

We are all aware of the fact that the small-town,
general practitioner is disappearing and we also know
most of the reasons why. One of these is the great
trend in medical education toward specialization which
has developed during the past few years. Of the 21,000
physicians in the Armed Forces who replied to a recent
American Medical Association questionnaire, more than
13,000 indicated that they wished to take enough post-
graduate work to become certified as specialists. At
present there are approximately 13,000 specialists regis-
tered, so that would double their numbers. One cannot
help but wonder whether those in charge of medical
education throughout the country have not largely for-
gotten that someone still must take care of the ordinary
illnesses which people still have. At most medical schools
very little is done to encourage graduates to enter gen-
eral practice, and particularly so in small towns. In
fact, at least some of the specialty boards definitely dis-
courage students on that point and urge them to begin
their training for specialization immediately after grad-
uation. It is difficult for some of us to understand this,
particularly when we realize that most of the original
specialists and founders of the present system of specialty
boards were general practitioners themselves to begin
with. Furthermore, it is my firm belief that these men
profited by general practice and that it definitely con-
tributed toward making them the eminent specialists
which they are.

It is now quite apparent that neither the opportunity
to serve our fellow men, nor the excellent chances for
reasonable financial success, will induce these younger
men to locate in the smaller towns. Considering all this
and in view of the widespread ambition to specialize,
why could not these young men be given credit toward
specialty rating for a certain period of time spent in
general practice — -say one year of credit for a minimum
of three years as a general practitioner? At the present
time most, if not all, of the boards do allow some credit
for time served in the Armed Forces. Without in any
way detracting from the value of such service, it is dif-
ficult to see why time spent in general practice would
not be just as valuable.

I entertain no illusions that such a plan would solve

this problem, but I do believe that it would be a con-
structive measure in the right direction.

Before leaving the subject of physician shortage I
would like to say a few words about Eye, Ear, Nose and
Throat specialists. As with general practitioners, and
perhaps next in importance, there is a great need for
them in South Dakota. At present there are at least
several places where such an individual is not only greatly
needed, but where his financial success would be assured.
However, as most of you know, Eye, Ear, Nose and
Throat specialists are not even trained any more as such.
They are either Otolaryngologists or Ophthalmologists
and the smaller communities that could very adequately
support one man with a reasonable amount of training
in both fields could not offer enough for two specialists.

Under the present system there seems to be no solu-
tion for this difficulty. We can, however, rightfully ask
this question. If those in authority over this field of
training share with the rest of us a sincere desire to fur-
nish good medical care to all the people, should they
not take positive steps to correct this situation?

Returning to the subject of constructive measures for
our Association, one of the utmost importance would be
an effective, voluntary, prepaid medical and hospital in-
surance plan in South Dakota. This type of insurance
is now available in almost every state except ours. As
evidenced by its rapid growth, it is something the people
want. Furthermore, the American Medical Association
has finally not only fully endorsed it, but is now actively
sponsoring a nation-wide plan of voluntary, prepaid med-
ical care similar to the Blue Cross. It is well to bear in
mind that such insurance is now considered, by those
in a position to know, as one of our most effective
weapons against socialized medicine or Federal compul-
sory health insurance.

During the last state legislative session, our Associa-
tion made a sincere attempt to have necessary legislation
passed which would enable it to introduce voluntary,
prepaid medical care into South Dakota. However, such
strong opposition was encountered both from within and
without our professional ranks that the attempt was a
complete failure.

It is hoped that within the next few months either
some plan which does not require new legislation will be
developed, or that those who were previously in opposi-
tion will be able to change their opinions, especially in
view of new developments since the last session of the
state legislature.

There are several other worthwhile measures which
could be considered. Among them is rejuvenation of the
Inter-Allied Council. This at one time had a very good
start and if developed to its fullest could be a powerful
force in the cause of professional freedom. Another, the
development of a real public relations program, both
within the medical profession itself and without, that is,
directed at the public concerning the relations of medi-
cine to the public. In such a program we should take
a positive position rather than continually accepting the
defensive attitude toward our critics, who have been both
numerous and aggressive in recent years. We should,
in particular, seize the opportunity to contact and co-

August, 1946

263

operate with other organized groups, professional or lay,
who are either opposed to compulsory health insurance
or have as yet made no decision on this vital subject.

Some constructive work could also be done toward
improving our methods of lobbying at state legislative
sessions. We are represented there by a very able attor-
ney, but when he calls for help from the Association
it usually comes in the form of "too little and too late.”
Mention should also be made about giving our full sup-
port to Federal legislation such as the newly introduced
Taft bill, with which I am sure you are all familiar.

The last subject for your consideration is a proposal
to strengthen our Association by establishing a state office
and hiring a full-time executive secretary. In this swift-
moving era of social and economic change it is impossible
for your officers, all of whom are practicing physicians,
to take adequate care of the business of this Association
without some additional personnel. No one can argue
that this business is not important enough to be looked
after. About the only objection to such a move is that
we will have to raise the dues and by so doing may lose
some members. To this I have a ready answer.

The next two or three years may be the last chance
we will ever have to help our Association reach its ob-
jective of better medical care for the people of South
Dakota through the voluntary, evolutionary and orderly
methods to which we and all the other citizens of this
Democracy have been accustomed.

The desire to protect our professional independence
should be almost as basic as the desire to protect our
family, our home, or our individual liberty.

A stronger Association can certainly accomplish more
toward this end than individual uncoordinated effort.
Consequently, it is not unreasonable to expect of every
practicing physician who does not want socialized medi-
cine, a little more of his money, his time and his mental
talent.

If or when we become harnessed by a Federal bureau-
cracy the problems now confronting us will of course all
be solved, and it will be quite unnecessary to maintain a
State Association except for purely scientific purposes.
If dues are then required, no doubt the Federal Social
Security Administrator will pay them for us.

ADDRESS OF THE PRESIDENT-ELECT

F. S. Howe, M.D.

Deadwood, South Dakota

To the House of Delegates and Members of the South Da-
kota State Medical Association:

I wish to take this opportunity to thank the members of
the association for the honor and privilege of serving you for
the ensuing year.

The medical profession of South Dakota has made an out-
standing record during World War II — a record in both mili-
tary and civilian practice. We are very glad, indeed, to pay
tribute to those members of the profession who served in the
armed forces. At the same time, older members of the profes-
sion in this state carried on during the emergency without re-
gard to their own health or convenience. They, too, deserve
special citation.

At this time we physicians are facing grave problems. Upon
their correct solution depends the entire future of our beloved
and honored profession.

One of the first we must take into account is membership.
According to the latest figures we have been able to obtain,
there are 354 physicians in the state. Of this number, 250 are
members of the State Association.

We must become thoroughly organized if we are going to
make our influence felt. It is essential that each district society
makes a drive for more members. Each local society must meet
regularly, put on good scientific programs, personally invite
non-members to attend and use every effort to make it worth-
while for them to join.

Nationally, the American Medical Association has 125,000
members out of a total of 175,000 physicians in the United
States. Both the A M. A. and the State associations should
make every possible effort to secure additional members and
perfect their organizations. A "united front” is an abused
phrase just now, but a united front is what the medical pro-
fession needs in one of the most critical periods in its history.

A second problem we face is a serious shortage of physicians
in this state, with the probability that we have a still more
serious condition ahead of us. A number of counties are with-
out a single M.D. We must recognize that the young physi-
cian just out of hospital or residency is not going to start prac-
tice without adequate hospital facilities.

Good highways and modern fast transportation have changed
the medical picture. One solution which has been recommended
repeatedly is the building of modern hospitals in isolated com-

munities, porbably by the federal government. This is a con-
troversial matter, but it is mv considered opinion that hospitals
alone will not improve conditions. Where are the doctors com-
ing from? Modern X-ray equipment, laboratories, facilities for
taking electrocardiograms and basal metabolisms are of little
or no value without trained men to interpret the findings.
Modern operating rooms and sterilizing equipment are useless
without a trained surgeon.

The most feasible solution would appear to be small emer-
gency hospitals in isolated communities, with an M.D. or even
a well trained graduate nurse in charge and good ambulance
service available at all times to rush the patient to the nearest
well equipped and well staffed hospital. As I said before, this
is a controversial matter and some of you may not agree with
me If you do not, I hope to hear your opinions brought out
in later discussions. In view of rapidly changing conditions,
however, our position cannot remain static. We face facts,
gentlemen. Some of them are not to our liking, but as has
been said, a fact is a stubborn thing.

This is true of our most timely and pressing problem, often
threatened, now at our very doorstep — socialized medicine.
I believe we all agree that if and when the Murray-Wagner
bill passes we shall have socialized medicine to all intents and
purposes.

At the same time, as physicians we must recognize that there
is a public demand for some pre-payment plan. It is this de-
mand by the layman that has given the politicians the excuse
they needed. If the medical profession does not institute such
a plan the politicians will do it for us.

The A.M.A. plan already advanced gives us a basis for
working out a pre-payment plan. Many of the states have
already adopted variations of this plan and they appear to be
working out fairly well.

South Dakota, composed largely of rural communities and
small cities, not highly industrialized, makes for a difficult sit-
uation. It is obviously impossible to cover all minor illnesses,
with our limited supply of physicians and no immediate pros-
pect of many more. Both doctors and hospitals would be so
over-burdened that a person really seriously ill could not get
the attention he needed so badly. At the same time, the com-
pulsory Murray-Wagner bill designed for big industrial cities
would be particularly galling in its application here.

264

The Journal Lancet

I believe that South Dakota, through its State Medical As-
sociation, must take necessary measures toward working out a
practical voluntary pre-payment plan that would fit our needs
in this state. I believe we must do this immediately.

Socialized medicine is not understood by the layman and in
proportion to his lack of understanding the superficial aspects
sound good to him. Sponsors of the Wagner-Murray bill harp
on two strings. They say that most people are now securing
poor medical care or none at all. They assume that under
socialized medicine everybody would have excellent care. We
know that neither of these propositions is true.

The layman does not realize that trained physicians, the
very people who give him medical care under any system, are
opposed to socialized medicine almost to a man. He does not
know why they oppose it. Selfishness, the politician says. Here
we have a job of education to perform.

Another of our problems centers around the various medical
drives. The Infantile Paralysis drive, the Cancer drive, the
Tuberculosis campaign, and research and clinics on heart dis-
ease should all be coordinated and combined in the interests

of efficiency. At the present time, because some drives have
clever publicity and advertising they are over-financed while

others of much greater importance such as cancer and heart
disease, are not given the necessary financial support for prog-
ress. May I suggest that the program for coordination of these
different drives could well be an important part of the work
of the Ladies Auxiliary? I believe that they are in a position
to do very efficient work along these lines.

You have heard the suggestion previously made that we hire
a full-time executive secretary. I should like to endorse this
program. The time has come when we need such a man.

However, an intensive sales campaign must be carried on
if we are to hold and enlarge our membership while we are
increasing our dues to employ a good full-time man. Those
of us actively in the work know its necessity but we must make
our other members and prospective new members realize it.

In closing, I ask for the earnest, active support of all our

members. It is only by the combined efforts of all of us that

we can hope to accomplish the many tasks we must perform
in the critical years ahead.

SOUTH DAKOTA STATE MEDICAL ASSOCIATION

ROSTER-1946

PRESIDENT

M R. Gelber Aberdeen

SECRETARY

P. V. McCarthy Aberdeen

Adams, John F. San Dimas, Calif.

Alway, J. D. Aberdeen

Bates, W. A. Aberdeen

Bloemendall, G. J. Ipswich

Brenckle, J. E. Mellette

Brinkman, W. C. Veblen

Bruner, J. E. Aberdeen

Bunker, Paul G. Aberdeen

Calene, John L Aberdeen

PRESIDENT

A. Willen Clark

SECRETARY

G. R Bartron Watertown

Adams, M. E. Clark

Bartron, G. R Watertown

Bartron, H. J. Watertown

PRESIDENT

G. H. G ulbrandsen Brookings

SECRETARY

C. M. Kershner Brookings

Baughman, D. S. Madison

Boyd, F. E. Flandreau

Butler, C. A. Hot Springs

PRESIDENT

O A. Kimble Murdo

SECRETARY

M. M. Morrissey .... .. ... Pierre

Carney, J. G. Los Angeles

Collins, E. H Gettysburg

MEMBERSHIP BY DISTRICTS

ABERDEEN DISTRICT NO. 1
Chichester, J. G. Redfield

Cooley, Frank H. Aberdeen

Damm, W. P. Redfield

Drissen, E. M. .... .... Britton

Eckrich, J. A. Aberdeen

* Elward, L. R. . __ Doland

Farrell, W. D. Aberdeen

Gelber, M. R. Aberdeen

Graff, Leo W. . . Britton

Keegan, Agnes Aberdeen

King, H. I ... Aberdeen

King, Owen Aberdeen

* K ruzich, S. J. Aberdeen

Marvin, T. R. Faulkton

Mayer, R. G. ... Aberdeen

WATERTOWN DISTRICT NO. 2

Bates, J S. .... Lake Preston

Brown, H, R. ... Watertown

Christianson, A. H. . Clark

* Crawford, J. H Sr. Watertown

* Hammond, M. J. ._ Watertown

Hickman, N. L. Bryant

Jorgenson, M. C. Watertown

Kenny, H. T. Watertown

Kilgard, R. M. Watertown

Larsen, M. W. ... Watertown

MADISON DISTRICT NO. 3

Davidson, Magni Brookings

Drobinsky, M. Estelline

Grove, E. H. Arlington

Gulbrandsen, G. H. Brookings
Hofer, E. A. .... Howard

Jordon, L. E. Chester

Kershner, C. M. Brookings

Miller, H. A. Brookings

Muggly, J. A. Madison

PIERRE DISTRICT NO. 4

Cottam, Gilbert Pierre

Cowan, J. T. Pierre

Creamer, F. H. ... .... Dupree

Embree, V. W. Onida

* Hart, B. M. Los Angeles

Kimble, O. A. .... Murdo

Martin, H. B. Harrold

McBroom, D. E. Redfield

McCarthy, P. V. Aberdeen

Murdy, Beecher C Aberdeen

Murdy, Robert Aberdeen

Pittenger, Earl A. Aberdeen

Ranney, T. P. Aberdeen

Rodine, John C. Aberdeen

Rudolph, E. A. Aberdeen

Scallin, Paul R Redfield

Schuchardt, I. L. Aberdeen

Waldorf, C. E. Redfield

★Wayne, D. M. Redfield

Weishaar, Chas. E. Aberdeen

White, Walter E. Ipswich

Whiteside, J. D. Aberdeen

Magee, W. G. . Watertown

Maxwell, R. T. Clear Lake

Mclntire, P S. Bradley

Randall, O. S. Watertown

Richards, G. H. Sioux Falls

Ross, Wm. Watertown

Rousseau, M. C. Watertown

Scheib, A. P. Watertown

Walters, S. J. Watertown

Willen, Abner . Clark

Peeke, A. P. Volga

Sherwood, C. E. Madison

Tank, M. C. Brookings

* Torwick, E. E. Volga

Watson, E. S. ... ... Brookings

Westaby, J. R. Madison

* Westaby, R. S. Los Angeles

Whitson, G. E. Madison

Willoughby, F. C. Howard

Morrissey, M. M. Pierre

Murphy, J. C. . . . Murdo

Northrup, F. A. . Pierre

Riggs, T. F. Pierre

Robbins, C. E. Pierre

★Salladay, I. R. Pierre

Triolo, A. Pierre

August, 1946

265

PRESIDENT

H. L. Saylor Huron

SECRETARY

H. P. Adams Huron

Adams, H. P. ... Huron

PRESIDENT

E. C. Bobb Mitchell

SECRETARY

D. R. Mabee Mitchell

Auld, C. V. _ _ Plankinton

Ball, W. R Mitchell

Beukelman, W. H. Stickney

* Bobb, B. A. Monrovia, Calif.

PRESIDENT

R. Reagan Sioux Falls

SECRETARY

C. J. McDonald Sioux Falls

Billingsly, P. R Sioux Falls

Billion, T. J. Jr. Sioux Falls

* Billion, T. J. Sr. Sioux Falls

Breit, Donald H. Sioux Falls

Clark, J. C. Sioux Falls

Cottam, G. I. W. Sioux Falls

★Craig, Allen Sioux Falls

★Cunningham, R. Sioux Falls

Dehli, H. M. Colton

Devall, F. C. Garretson

Donahoe, S. A. .... Sioux Falls

Donahoe, W. E. Sioux Falls

Dumistra, F. Sioux Falls

Dulaney, C. H. Canton

Eggers, Maynard Sioux Falls

PRESIDENT

A. P. Reding Marion

SECRETARY

J. A. Hohf Yankton

Abts, E. J. Yankton

Abts, F. J. Yankton

Blezek, F. M. Tabor

Brookman, L. J. Vermillion

Bushnell, Wm. F. Elk Point

Conner, E. I. Alcester

PRESIDENT

W. A. Dawley Rapid City

SECRETARY

H. E. Davidson Lead

Bailey, J. D. Rapid City

Borgmeyer, H J. Rapid City

Brock, E. H. Rapid City

Butler, J. M. Hot Springs

Christian, P. C. Hot Springs

Clark, B. S. Spearfish

Clark, O. H. Newell

* Cramer, L. L. Hot Springs

Crane, H. L. L’Oroya, Peru

Davidson, H. E. Lead

Davis, J. H. Belle Fourche

HURON DISTRICT NO. 5

★ Buchanan, R. A. Huron

Burman, G. E. Carthage

Hagin, J. C. Miller

Jacoby, Hans Huron

Lenz, B. T. Huron

Pangburn, M. W. Miller

MITCHELL DISTRICT NO. 6
Bobb, C. S. Mitchell

Bobb, E. C. Mitchell

Bollinger, W. F. Parkston

Cochran, F. B. Plankinton

Delaney, Robert .... . Mitchell

Delaney, W. A. Jr. Mitchell

Delaney, W. A. Sr. Mitchell

DeVries, Albert Platte

Dick, L. C. Spencer

* Freyberg, F. W. Mitchell

Gillis, F. D. . .. Mitchell

Jones, J. P. Mitchell

SIOUX FALLS DISTRICT NO. 7

Erickson, E.

Sioux Falls

Erickson, O. C.

.... Sioux Falls

Fiske, R. R.

Flandreau

★ Fitzgibbons, G.

Sioux Falls

* Gage, E. E.

Sioux Falls

Gregg, J. B.

.... Sioux Falls

Groebner, O. A.

Sioux Falls

Grove, A. F.

.... Dell Rapids

Grove, M. S.

Sioux Falls

Hanson, O. L.

Valley Springs

Hofer, E. J.

Freeman

* Hummer, H.

Sioux Falls

Hyden, Anton

..... Sioux Falls

Keller, S. A

Sioux Falls

Kemper, C. E.

Viborg

Kittelson, J. A.

Sioux Falls

Lamb, Hazel

Sioux Falls

Lanam, M. O.

Sioux Falls

Leraan, L. G.

Hartford

McDonald, C. J

. Sioux Falls

* Mullen, R. W. ......

Sioux Falls

YANKTON DISTRICT NO. 8

Duggan, T. A.

Wagner

Fairbanks, W. H

Vermillion

Greenfield, J C. ....

Avon

Haas, F. W

Yankton

Hills, W. C.

Yankton

Hohf, J. A

Yankton

Hohf, S. M.

Yankton

Hubner, R. F. ....

. Yankton

* Kalayjian, D. S.

Parker

* Keeling, C. M.

Springfield

Johnson, Geo. E.

Yankton

Jordan, Geo. T.

Vermillion

BLACK HILLS DISTRICT NO. 9

Dawley, W. A.

Rapid City

Erickson, J. W.

.... Rapid City

Ewald, P. P.

Lead

Fleeger, R. B.

Lead

★Gilbert, Freeman J

Belle Fourche

Hare, Lyle

Spearfish

Hayes, Paul W. ..

.... Hot Springs

Howe, F. S.

Deadwood

★ Hummer, F. L.

— Lead

Jackson, A. S.

Lead

Jackson, R. J.

Rapid City

Jernstrom, K E.

Rapid City

Kegaries, D. L.

Rapid City

* Knoll, William

.... Hot Springs

* Krasner, C. D.

Hot Springs

Lampert, A. A.

Rapid City

Lemley, R. E.

. ... Rapid City

Manning, F. E. ....

Custer

Saxton, W. H. Huron

Saylor, H. L. ... Huron

Shirley, J. C. Huron

Tschetter, J. S. Huron

Tschetter, Joseph Huron

Tschetter, P. S. Huron

Jones, T. D. Chamberlain

* Keene, F. F. _ Wessington Springs

Lloyd, J. H. Mitchell

Mabee, D. R. .... Mitchell

Mabee, O. J. Mitchell

Moran, C. S. Mitchell

McGreevy, F. V. Sioux Falls

Rieb, W. G. Parkston

Stegman, S. B. Salem

Tobin, F. J. Mitchell

Tobin, L. W. Mitchell

Weber, R. A. Mitchell

Nelson, J. A. .. Sioux Falls

Nessa, N. J. Sioux Falls

★Nietfield, A. B. Sioux Falls

Nilsson, F. C. Sioux Falls

★Olson, Orland Sioux Falls

Opheim, O. V. Sioux Falls

Pankow, L. J Sioux Falls

Parke, L. L. Sioux Falls

Reagan, R. Sioux Falls

Rich, E. L. ... Sioux Falls

★Sackett, R. Parker

Sercl, W. F. Sioux Falls

Stenberg, E. S. Sioux Falls

Stevens, G. A. Sioux Falls

Stevens, R. G. Sioux Falls

Unruh, B. H. . Sioux Falls

Van Demark, G. E.. . Sioux Falls

Volin, H. .... Lennox

Wallis, Marianne Sioux Falls

★Zellhoefer, H. Sioux Falls

Zimmerman, Goldie Sioux Falls

Joyce, E. Hurley

Lacey, V. I. Yankton

Lietzke, E. T. Beresford

McVay, C. B. .... Yankton

Ohlmacher, J. C. Vermillion

Reding, A. P. Marion

Schwartz, E. R. Wakonda

Smith, A. J. Yankton

Stansbury, E. M. Vermillion

Steiner, Peter K. Lemmon

Struble, A. J. ...... Centerville

Tauber, K. S. Yankton

Matlock, W. L. Deadwood

Mattox, N. E. Lead

* Mauss, I. H. Rapid City

★McGonigle, J. P. Rapid City

Merryman, M. P. Rapid City

Meyer, W. L. Sanator

* Miller, G. H. Spearfish

Mills, G. W. Wall

Morse, W. E. Rapid City

Morsman, C. F. Hot Springs

Neves, Carl A. Hot Springs

Newby, H. D. Rapid City

★Nyquist, R. H. Ft. Meade

O’Toole, T. F. Rapid City

Owen, G. S. Rapid City

Owen, N. T. ... Rapid City

Pemberton, M. O. Deadwood

Radusch, F. J. Rapid City

266

The Journal Lancet

* Railborn, R. L.

Hot Springs

Smiley, J. C.

Deadwood

Sundet, N. J.

Kadoka

* Roberts, F. J.

Hot Springs

* Smith, F. C.

Hot Springs

Swift, C. L.

Martin

* Rosenstock, Chas.

Hot Springs

Soe, Carl A

- Lead

Threadgold, J. O.

Belle Fourche

* Sackett, R. F.

Camp Rapid

Spain, M. L. ...

.. Rapid City

* Townsend, L. J.

Belle Fourche

Sadock, T. R.

Wagner

* Stewart, J L.

Spearfish

Welty, D. M.

.. Hot Springs

Sherrill, S. F. Belle Fourche

★Stewart, M. J.

Sturgis

Williams, F. R.

Rapid City

Skogmo, B. R. .

Hot Springs

Stewart, N. Wells

Lead

★Zarbaugh, G. F.

Deadwood

ROSEBUD DISTRICT NO. 10

. ... Winner

Malster, R. N.

Carter

Quinn, R. J.

Burke

NORTHWEST DISTRICT NO. 11

PRESIDENT

★ Caty, Robert

... Mobridge

Harris, L D. ...

Mobridge

W. A. George

Selby

Christie, Roy E.

Eureka

Lowe, C. E. ._

Mobridge

★ Duncan, C. E.

Bollock

★Sawyer, James G. ...

Mobridge

SECRETARY

George, W. A.

. Selby

Spiry, A. W.

Mobridge

L. D. Harris

.... Mobridge

* Fleishman, Harold ...

Totten, F. C.

Lemmon

Cheyi

enne Agency

WHETSTONE VALLEY DISTRICT NO.

PRESIDENT

Duncan, William ... __

Webster

Karlins, W. H.

Webster

Faris F. Pfister

.... Webster

Flett, Chas. . .

Milbank

Peabody, P. D. Jr. .

Webster

Gregory, D. A.

Milbank

Pfister, Faris

Webster

SECRETARY

Hawkins, A. P.

Waubay

Younker, F. T. ._ ....

— . Sisseton

W. H. Karlins

Webster

Hedemark, T. A.

Thief River

Falls, Minn.

Brauer, Harry H ...

Sisseton

Jacotel, J. A.

Milbank

* Honorary Member

Cliff, F. N. .

Milbank

Judge, W. T.

Milbank

★Armed Service

ROSTER

South Dakota State Medical Association- 1946

Abts, E. J. .

Yankton

Abts, F. J.

Yankton

Adams, H. P.

Huron

Adams, J. F. San Dimas, Calif.

Adams, M. E.

Clark

Alway, J. D.

Aberdeen

Auld, C. V.

Plankinton

Bailey, J. D.

.... Rapid City

Ball, W. R.

Mitchell

Bartron, G. R.

Watertown

Bartron, H. J.

Watertown

Bates, J. S.

Lake Preston

* Bates, W. A

Aberdeen

Baughman, D. S. „

Madison

Beukelman, W. H.

Stickney

Billingsly, P. R.

... Sioux Falls

Billion, T. J. Jr

.... Sioux Falls

* Billion, T. J. Sr.

Sioux Falls

Bloemendall, G. J. .

Ipswich

Blezek, F. M.

Tabor

* Bobb, B. A. M

onrovia, Calif.

Bobb, C. S.

Mitchell

Bobb, E. C. ....

Mitchell

Bollinger, W. F.

Parkston

Borgmeyer, H. J

Rapid City

Boyd, F. E.

Flandreau

Brauer, Harry H

.... Sisseton

Breit, Donald H.

Sioux Falls

Brenckle, J. E.

Mellette

Brinkman, W. C. ...

Veblen

Brock, E. H.

Rapid City

Brookman, L. J.

Vermillion

Brown, H. R.

Watertown

Bruner, J. E.

Aberdeen

★ Buchanan, R. E.

Huron

Bunker, Paul G.

Aberdeen

Burman, G. E. _.

Carthage

Bushnell, Wm. F. ...

Elk Point

* Butler, C. A. ...

Hot Springs

Butler, J. M.

Hot Springs

Calene, John L.

... Aberdeen

Carney, J. G Los Angeles, Calif.

★Caty, Robert

Mobridge

Chichester, J. G. __ . Redfield

* Christian, P. C. Hot Springs

Christianson, A. H. .... .... Clark

Christie, Roy E. Eureka

Clark, B. S. Spearfish

Clark, J. C. Sioux Falls

Clark, O. H. Newell

Cliff, F. N. Milbank

Cochran, F. B. Plankinton

Collins, E. H. Gettysburg

Conner, E. I. Alcester

Cooley, Frank H. Aberdeen

Cottam, Gilbert __ Pierre

Cottam, G. I. W. Sioux Falls

Cowan, J. T. Pierre

★Craig, Allen Sioux Falls

* Cramer, L. L Hot Springs

Crane, H. L. L’Oroya, Peru

* Crawford, J. H. Sr. Watertown

Creamer, F. H. .... .... Dupree

★Cunningham, R. .... .... Sioux Falls

Damm, W. P. Redfield

Davidson, H. E. Lead

Davidson, Magni Brookings

Davis, J. H Belle Fourche

Dawley, W. A. Rapid City

Dehli, H. M. Colton

Delaney, Robert Mitchell

Delaney, W. A. Jr Mitchell

Delaney, W. A. Sr. Mitchell

Devall, F. C. Garretson

DeVries, Albert Platte

Dick, L. C. Spencer

Donahoe, S. A. .... Sioux Falls

Donahoe, W. E. Sioux Falls

Drissen, E. M. Britton

Drobinsky, M. Estelline

Duggan, T. A. Wagner

Dulaney, C. H. Canton

Dumistra, F. Sioux Falls

* Duncan, C. E. .. Pollock

Duncan, William Webster

Eckrich, J. A. Aberdeen

Eggers, Maynard Sioux Falls

* Elward, L. R. Doland

Embree, V. W. Onida

Erickson, E. Sioux Falls

Erickson, J. W. __ Rapid City

Erickson, O. C. Sioux Falls

Ewald, P. P. Lead

Fairbanks, W. H. Vermillion

Farrell, W. D. Aberdeen

Fiske, R. R. Flandreau

★Fitzgibbon, G. Sioux Falls

* Fleishman, Harold

Cheyenne Agency

Fleeger, R. B. Lead

Flett, Chas. Milbank

* Freyberg, F. W. Mitchell

* Gage, E. E. Sioux Falls

Gelber, M. R. Aberdeen

George, W. A. Selby

* Gilbert, Freeman .... Belle Fourche

Gillis, F. D. Mitchell

Graff, Leo W. Britton

Greenfield, J. C. Avon

Gregg, J. B. Sioux Falls

Gregory, D. A. Milbank

Groebner, O. A. Sioux Falls

Grove, A. F. Dell Rapids

Grove, E. H. ... Arlington

Grove, M. S. Sioux Falls

Gulbrandsen, G. H Brookings

Haas, F. W. Yankton

Hagin, J. C. Miller

* Hammond, M. J. Watertown

Hanson, O. L. Valley Springs

Hare, Lyle Spearfish

Harris, L. D. Mobridge

* Hart, B. M Los Angeles, Calif.

Hayes, Paul W. Hot Springs

Hawkins, A. P. Waubay

Hedemark, T. A.

Thief River Falls, Minn.

Hickman, N. L. Bryant

Hills, W. C Yankton

August, 1946

267

Hot'er, E. A. Howard

Hofer, E. J. Freeman

Hohf, J. A. Yankton

Hohf, S. M. Yankton

Howe, F. S. Deadwood

Hubner, R. F Yankton

FHummer, F. L. Lead

! Hummer, H. R. Sioux Falls

Hyden, Anton Sioux Falls

Jackson, A. S. Lead

Jackson, R. J. Rapid City

Jacoby, Hans .... — - - - Huron

Jacotel, J. A. Milbank

Jernstrom, R. E. Rapid City

Johnson, Geo. E. Yankton

Jones, J. P. Mitchell

Jones, T. D. Chamberlain

Jordan, Geo. T. Vermillion

Jordan, L. E. Chester

Jorgenson, M. C. Watertown

Joyce, E Hurley

Judge, W. T. Milbank

: Kalayjian, D. S. Parker

Karlins, W. H. Webster

Keegan, Agnes Aberdeen

; Keeling, C. M. Springfield

! Keene, F. F. Wessington Springs

Kegaries, D. L. Rapid City

Keller, S. A. Sioux Falls

Kemper, C. E. Viborg

Kenny, H. T. Watertown

Kershner, C. M. Brookings

Kilgaard, R. M. Watertown

Kimble, O. A. — - Murdo

King, H. I. — - — Aberdeen

King, Owen Aberdeen

Kittelson, J. A. Sioux Falls

* Knoll, Wm. .... Hot Springs

* Krasner, C. D. Hot Springs

kKruzich, S. J. Aberdeen

Lacey, V. I. Yankton

Lamb, Hazel Sioux Falls

Lampert, A. A. ._ Rapid City

Lande, L. E. Winner

Lanam, M. O Sioux Falls

Larsen, M. W. Watertown

Lemley, R. E. Rapid City

Lenz, B. T. Huron

Leraan, L. G. Hartford

Lietzke, E. T. Beresford

Lowe, C. E. Mobridge

Lloyd, J. H. .... Mitchell

Mabee, D. R. Mitchell

Mabee, O. J. Mitchell

Magee, H. G. ... Watertown

Malster, R. N. . _ Carter

Manning, F. E. . Custer

Martin, H. B. .. Harrold

Marvin, T. R. Faulkton

Matlock, W. L. .... Deadwood
Mattox, N. E. . . Lead

* Mauss, I. H. Rapid City

Mayer, R. G. Aberdeen

Maxwell, R. T Clear Lake

McBroom, D. E. Redfield

McCarthy, P. V. Aberdeen

McDonald, C. J. S ioux Falls

McGreevy, F. V. . .. Sioux Falls

★McGonigle, J. P. Rapid City

Mclntire, P. S. Bradley

McVay, C. B. _. Yankton

Merryman, M. P. . Rapid City
Meyer, W. L. Sanator

* Miller, G. H. ... Spearfish

Miller, H. A. Brookings

Mills, G. W. .. Wall

Moran, C. S. .... ... Mitchell

Morse, W. E. .... Rapid City

Morseman, C. F . Hot Springs

Morrissey, M. M. _ Pierre

Muggly, J. A. .... Madison

* Mullen, R. W. Sioux Falls

Murdy, Beecher C. Aberdeen

Murdy, Robert Aberdeen

Murphy, J. C. ... Murdo

Nelson, J. A. Sioux Falls

Nessa, N. J. Sioux Falls

Neves, Carl L. Hot Springs

Newby, H. D. Rapid City

★Nietfield, A. B. Sioux Falls

Nilsson, F. C. Sioux Falls

Northrup, F. A. Pierre

★Nyquist, R. H. Ft. Meade

Ohlmacher, J. C. Vermillion

★Olson, Orland Sioux Falls

Opheim, O. V. Sioux Falls

O’Toole, T. F. Rapid City

Owen, G. S. Rapid City

Owen, N. T. Rapid City

Pangburn, M. W. Miller

Pankow, L. J. _ Sioux Falls
Parke, L. L. Sioux Falls

Peabody, P. D. Jr Webster

Peeke, A. P. Volga

Pemberton, M. O. Deadwood

Pfister, Faris Webster

Pittenger, E. A. Aberdeen

Quinn, R. J Burke

Radusch, F. J Rapid City

* Railborn, R. L. Hot Springs

Randall, O. S. Watertown

Ranney, T. P. Aberdeen

Reagan, R. _ ... Sioux Falls

Reding, A. P. Marion

Richards, G. H. ... Sioux Falls

Rich, E. L. Sioux Falls

Rieb, W. G. Parkston

Riggs, T. F. Pierre

Robbins, C. E. Pierre

* Roberts, F. J. Hot Springs

Rodine, John Aberdeen

* Rosenstock, Chas. Hot Springs

Ross, Wm. Watertown

Rousseau, M. C. Watertown

Rudolph, E. A. Aberdeen

* Sackett, R. F. Camp Rapid

★Sackett, R. Parker

Sadock, T. R. Wagner

★Salladay, I. R. Pierre

Saxton, W. H. Huron

Saylor, H. L. Huron

★Sawyer, Jas. G. Mobridge

Scallin, Paul R. Redfield

Scheib, A. P. Watertown

Schuchardt, I. L. ...

Aberdeen

Schwartz, E. R.

Wakonda

Sercl, W. F.

... Sioux Falls

Sherrill, S. F.

Belle Fourche

Sherwood, C. E.

Madison

Shirley, J. C. ...

Huron

Skogmo, B. R.

. Hot Springs

Smiley. J. C.

... Deadwood

* Smith, A. J ....

Yankton

Smith, F. C. ....

Hot Springs

Soe, Carl A.

Lead

Spain, M. L.

Spiry, A. W.

.... Rapid City

Mobridge

Stansbury, E. M. ...

.... Vermillion

Stegman, S B.

Salem

Steiner, Peter K.

Stenberg, E. S.

........ Lemmon

.... Sioux Falls

Stevens, G. A. _

... Sioux Falls

Stevens, R. G. ..

... Sioux Falls

* Stewart, J . L.

★Stewart, M. J.

Sturgis

Stewart, N. Wells ....

Lead

Studenberg, J. E.

Winner

Sundet, N. J.

Kadoka

Swift, C. L.

Martin

Tank, M. C.

Brookings

Tauber, K. S.

Wagner

Threadgold, J O

Belle Fourche

Tobin, F. J. ....

... .... Mitchell

Tobin, L. W.

... .. Mitchell

* Torwick, E. E

Volga

Totten, F. C.

Lemmon

* Townsend, L. J

Belle Fourche

Triolo, A.

Tschetter, J. S. ..

Pierre

Huron

Tschetter, Jos.

Huron

Tschetter, P S.

Huron

Unruh, B. H.

- . Sioux Falls

Van Demark, G. E.

Sioux Falls

Volin, H. P.
Waldorf, C. E.

Lennox

. Redfield

Wallis, Marianne

. . Sioux Falls

Walters, S. J.

Watertown

★Wayne, D. M. __ _.

Redfield

Watson, E. S.

Brookings

Weber, R. A.

Weishaar, Chas. E. .

Mitchell

_ .... Aberdeen

Welty, D. M.

. Hot Springs

Westaby, J. R. .... __

Madison

* Westaby, R. S

Madison and Los Angeles

White, W. E. .

Ipswich

Whiteside, J. D.

Aberdeen

Whitson, G. E.

Madison

Widen, Abner

Clark

Williams, F. R.
Willoughby, F. C. ...

Rapid City

Howard

Younker, F. T.

Sisseton

★Zarbaugh, G. F.

Deadwood

★Zellhoefer, H. .

Zimmerman, Goldie

* Honorary Member
★Armed Service

Sioux Falls

268 The Journal Lancet

WOMEN’S AUXILIARY TO THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION

Officers

President .. Mrs. William Duncan, Webster

President-elect .... Mrs. H. Russell Brown, Watertown
First Vice President Mrs. Myron W. Larsen, Watertown

Second Vice President Mrs. J. H. Lloyd, Mitchell

Recording Secretary .... Mrs. Kurt S. Tauber, Milbank
Cor. Sec. and Treas. - Mrs. Paul G. Bunker, Aberdeen

Past President Mrs. G. S. Adams, Yankton

Chairmen of Standing Committees

Hygeid - (not appointed)

Bulletin Mrs. A. J. Struble, Centerville

Legislative Mrs. C. E. Robbins, Pierre

Organization Mrs. Myron W. Larsen, Watertown

Program Mrs. M. R. Gelber, Aberdeen

Public Relations and Publicity

Mrs. F. W. Minty, Rapid City

Historian Mrs. G. S. Adams, Yankton

South Dakota State Medical Benevolent Committee

Chairman Mrs. J. C. Hagin, Miller

Secretary-Treasurer C. E. Sherwood, M.D., Madison

Advisory Council

C. E. Sherwood, M.D., Chairman Madison

W. H. Saxton, M.D. Huron

C. E. Robbins, M.D. Pierre

President’s Report 1945-1946

Mrs. William Duncan, of Webster, was elected president of
the Women’s Auxiliary to the South Dakota State Medical
Association at its 36th annual meeting in Aberdeen, June 1-4,
1946. Other officers are: Mrs. H. Russell Brown, Watertown,
president-elect; Mrs. Myron W. Larsen, Watertown, first vice
president; Mrs. J. H. Lloyd, Mitchell, second vice president;
Mrs. Kurt S. Tauber, Milbank, recording secretary, and Mrs.
Paul G. Bunker, Aberdeen, corresponding secretary and treas-
urer.

Mrs. G. S. Adams, retiring president, gave a resume of her
annual reports sent to Miss Margaret N. Wolfe, our Executive
Secretary, Chicago, and to our National Historian, Mrs. David
B. Ludwig of Pittsburgh, also the war report for 1944-1946
which was sent to our national War Service Chairman, Mrs.
Rollo K. Packard of Chicago. The war report indicated that
all Doctor’s wives had continued their activities in hospital
work, Red Cross sewing and knitting, surgical dressings, hos-
pital guild work, canteen, nurses aide classes, ration boards,
cancer control drive, Gray Ladies, bond sale drives, World Re-
lief clothing drive, Girl Scouts, etc. One auxiliary member
served on the State Recruitment Committee of the U. S. Cadet
Nurse Corps and promoted the U. S. Cadet Corps at Sacred
Heart Hospital in Yankton.

At the close of another year we are happy to report that the
South Dakota Auxiliary has made progress in all phases of its
work and has increased its membership from 132 to 150 mem-
bers, which was our goal. Our slogan was "Every Doctor’s ■
Wife a Member.” The highlight of the convention was the
report that Whetstone Valley District No. 12 had been organ-
ized with nine members. We now have eleven organized and
one unorganized district. The smallest unit has four members, j
which is 100 per cent. The largest unit has twenty-six mem-
bers. Our first president, Mrs. R. D. Jennings of Hot Springs,
South Dakota, is still very active, although nearly 90 years of
age. She spent the winter in Tulsa, Oklahoma, where she
attended a meeting of the Oklahoma Auxiliary on May 7, 1946.

This year our Hygeia chairman obtained 62 subscriptions for
Hygeid, the largest number ever sold, and entered the National
contest, winning the Honorable Mention award.

Our Auxiliary programs this past year have been educa-
tional, social and legislative. Some of the subjects were: Pro-
motion of Public Health, Promotion of Hygeid and Child Cdre,
Promotion of the Bulletin, Juvenile Delinquency, Promotion of
Authentic Nutrition Programs, Doctor’s Day Observance, Pro-
motion of Cancer Control, Promotion of Benevolent Fund and
Auxiliary Cooperation to help plan a lasting World Peace and
Rehabilitation.

This past year we have had the privilege of hearing over
WNAX Radio every Tuesday evening, "The Doctors Talk it
Over.” The subjects proved most instructive and interesting.
The radio has just added a new series, "Venereal Diseases,”
which should contain valuable information.

At the close of our annual Medical Auxiliary meeting we
had the pleasure of hearing Dr. Gilbert Cottam, superintendent
of the State Board of Health, address us on the Wagner-
Murray-Dingell bill. Dr. Cottam had just returned from
Washington and his talk was very educational and entertaining.

Our Post War annual meeting in Aberdeen was an out-
standing success. The Hostess Auxiliary was wonderfully solici-
tous of us in every respect, their entertainment was delightful
and we are all most grateful to them for a successful and en-
joyable convention. The meeting adjourned with Mrs. William
Duncan, our new president, in the chair.

Benevolent Fund Report

The Benevolent Fund, established in 1939 by the Woman’s
Medical Auxiliary for indigent physicians and their families,
is now about twenty-five hundred dollars. At the annual meeting
it was voted that the bonds remaining in the Auxiliary treasury
be added to the Benevolent Fund and that the Benevolent Fund
Committee also consider using the funds on hand as a Student
Loan Fund for senior students. We also voted a donation to
our State Society for Crippled Children.

Mrs. G. S. Adams

ROSTER, 1946 — MEMBERSHIP BY DISTRICTS

ABERDEEN DISTRICT NO. 1

President — Mrs. I. L. Schuchardt Aberdeen

Secretary — Mrs. Paul G. Bunker Aberdeen

Bruner, Mrs. J. E. — . Aberdeen

Bunker, Mrs. P. G. Aberdeen

Calene, Mrs. J. L. - — Aberdeen

Cooley, Mrs. F. H. Aberdeen

Gelber, Mrs. M. R. Aberdeen

Mayer, Mrs. R. G. Aberdeen

Murdy, Mrs. B. C Aberdeen

Murdy, Mrs. Carson Aberdeen

Murdy, Mrs. Robert Aberdeen

Pittenger, Mrs. E. A. Aberdeen

Ranney, Mrs. T. P. Aberdeen

Rudolph, Mrs. E. A. Aberdeen

Schuchardt, Mrs. I. L. Aberdeen

WATERTOWN DISTRICT NO. 2

President — Mrs. M. C. Jorgenson Watertown

Secretary — Mrs. O. S. Randall Watertown

Brown, Mrs. H. R. .... Watertown

Hammond, Mrs. M. J. Watertown

Jorgenson, Mrs. M. C. - Watertown

Kilgard, Mrs. R. M Watertown

Larsen, Mrs. M. W. Watertown

Magee, Mrs. W. G. __Watertown j

Randall, Mrs. O. S. Watertown

Scheib, Mrs. A. P. Watertown

Vaughn, Mrs. James B. Castlewood

Walters, Mrs. Stanley J. ... Watertown

Richards, Mrs. G. H. Watertown i

Rousseau, Mrs. M. C. Watertown j|

MADISON DISTRICT NO. 3

President — Mrs. C. E. Sherwood Madison

Secretary — Mrs. J. R. Westaby Madison

Baughman, Mrs. D. S. Madison

Davidson, Mrs. M. Brookings

Grove, Mrs. E. H. Arlington

Gulbrandsen, Mrs. G. H. Brookings

Hofer, Mrs. E. A Howard J

Miller, Mrs. H. A. Brookings ;

Peeke, Mrs. A. P. Volga |

Sherwood, Mrs. C. E. .... ... Madison [

Tank, Mrs. M. C. ... Brookings i

Watson, Mrs. E. S. Brookings

Westaby, Mrs. J. R. Madison j

Whitson, Mrs. G. E. Madison

August, 1946

269

PIERRE DISTRICT NO. 4

President — Mrs. T. F. Riggs Pierre

; Secretary — Mrs. I. R. Salladay Pierre

Martin, Mrs. H. B. Harrold

Morrissey, Mrs. M. M. Pierre

, Northrup, Mrs. F. A. Pierre

Riggs, Mrs. T. F. Pierre

Robbins, Mrs. C. E. Pierre

I Salladay, Mrs. I. R. Pierre

Triolo, Mrs. A. .. Pierre

HURON DISTRICT NO. 5

President — Mrs. R. A. Buchanan Huron

Secretary— Mrs. John S. Tschetter Huron

'Adams, Mrs. H. P. Huron

Buchanan, Mrs. R. A. Huron

Hagin, Mrs. J. C. Miller

Jacoby, Mrs. Hans Huron

Lenz, Mrs. B. T. _ Huron

Saylor, Mrs. Howard Huron

Saxton, Mrs. W. H. Huron

Shirley, Mrs. J. C. Huron

Tschetter, Mrs. John S. Huron

Tschetter, Mrs. Joseph S. Huron

Tschetter, Mrs. Paul S. Huron

MITCHELL DISTRICT NO. 6

President — Mrs. F. D. Gillis Mitchell

Secretary — Mrs. D. R. Mabee ... . Mitchell

Ball, Mrs. W. R . ... Mitchell

Beukelman, Mrs. W. H. Stickney

Bobb, Mrs. C. S. Mitchell

Bobb, Mrs. E. C. Mitchell

Delaney, Mrs. W. A. Jr. Mitchell

Delaney, Mrs. W. A. Sr. Mitchell

Freyberg, Mrs. F. W Mitchell

Gillis, Mrs. F. D Mitchell

! Lloyd, Mrs. J. H. Mitchell

Mabee, Mrs. D. R. Mitchell

Mabee, Mrs. O. J. ..Mitchell

McGreevey, Mrs. J. V. Sioux Falls

Moran, Mrs. C. S. Mitchell

Rieb, Mrs. W. G. Parkston

Tobin, Mrs. F. J. Mitchell

i Tobin, Mrs. L. W Mitchell

Weber, Mrs. R. A Mitchell

SIOUX FALLS DISTRICT NO. 7

President- — Mrs. R. Reagan Sioux Falls

Secretary — Mrs. H. M. Delhi Colton

Treasurer — Mrs. L. J. Pankow Sioux Falls

Billion, Mrs. T. J. ... Sioux Falls

Brandon, Mrs. P. E. _. _ Sioux Falls

Delhi, Mrs. H. M. ..Colton

Donahoe, Mrs. S. A. Sioux Falls

Erickson, Mrs. E. G. Sioux Falls

Erickson, Mrs. O. C. Sioux Falls

Gage, Mrs. E. E. Sioux Falls

Grove, Mrs. M. S. Sioux Falls

Hanson, Mrs. O. A. Valley Springs

Hyden, Mrs. Anton Sioux Falls

Kittleson, Mrs. J. A. Sioux Falls

Lanam, Mrs. M. O. , ____ Sioux Falls

Leraan, Mrs. L. G. Sioux Falls

McDonald, Mrs. C. J. Sioux Falls

Nelson, Mrs. J. A. Sioux Falls

Nessa, Mrs. N. J. Sioux Falls

Nilsson, Mrs. F. C. Sioux Falls

Pankow, Mrs. L. J. Sioux Falls

Reagan, Mrs. R. Sioux Falls

j Sercl, Mrs. Wm. F. Sioux Falls

Stenberg, Mrs. E. S. Sioux Falls

Stevens, Mrs. G. A. Sioux Falls

Stevens, Mrs. R. G. .... Sioux Falls

Stone, Mrs. J. G. Sioux Falls

Ver Maelen, Mrs. Peter Sioux Falls

Volin, Mrs. H. P ..Lennox

YANKTON DISTRICT NO. 8

President — Mrs. E. R. Schwartz ... Wakonda

Secretary — Mrs. R. F. Hubner Yankton

Abts, Mrs. E. J. ..Yankton

Abts, Mrs. F. J. Yankton

Adams, Mrs. G. S. Yankton

Blezek, Mrs. F. M. Tabor

Brookman, Mrs. L. J. Vermillion

Duggan, Mrs. T. A. Wagner

Greenfield, Mrs. J. C Avon

Haas, Mrs. F. W. Yankton

Hohf, Mrs. J. A. Yankton

Hubner, Mrs. R. F. Y ankton

Johnson, Mrs. G. E. Yankton

Joyce, Mrs. E. Hurley

Kirby, Mrs. W. M. Springfield

Lacey, Mrs. V. I. Yankton

McVay, Mrs. C. B. Yankton

Morehouse, Mrs. E. M. Yankton

Ohlmacher, Mrs. J. C. Vermillion

Reding, Mrs. A. P. ~ ... Marion

Schwartz, Mrs. E. R. — VCGkonda

Smith, Mrs. A. J. Yankton

Stansbury, Mrs. E. M. Vermillion

Struble, Mrs. A. J Centerville

Tauber, Mrs. K. S. .Milbank

Trieweiler, Mrs. J. E. Yankton

BLACK HILLS DISTRICT NO. 9

(No acting president)

Secretary — Mrs. F. W. Minty .... Rapid City

Bailey, Mrs. J. D. Rapid City

Brock, Mrs. E. H. Rapid City

Davis, Mrs. J. H. Belle Fourche

Hare, Mrs. Lyle Spearfish

Howe, Mrs. F. S. .... Deadwood

Jackson, Mrs. A. S. Lead

Jernstrom, Mrs. R. E. Rapid City

Kegaries, Mrs. D. L. Rapid City

Meyer, Mrs. W. L. Sanator

Minty, Mrs. F. W. .. Rapid City

Morse, Mrs. W. E. Rapid City

Newby, Mrs. H. D. ... ......... Rapid City

O’Toole, Mrs. T. F. Rapid City

Spain, Mrs. M. L. .... Rapid City

Wills, Mrs. G. W. .... ... Wall

ROSEBUD DISTRICT NO. 10

(No acting president)

Secretary — Mrs. R. V. Overton ......... Winner

Lande, Mrs. L. E. Winner

Overton. Mrs. R. V. Winner

Quinn, Mrs. R. J. __ . Burke

Studenberg, Mrs. J. E. Winner

NORTHWEST DISTRICT NO. 11

(currently non-active)

WHETSTONE VALLEY DISTRICT NO 12

President — Mrs. Wm. Duncan ... Webster

Secretary — Mrs. F. T. Younker Sisseton

Brauer, Mrs. H H. .... . .... Sisseton

Cliff, Mrs. F. N. Milbank

Duncan, Mrs. Wm. Webster

Gregory, Mrs. D. A. ... Milbank

Hawkins, Mrs. A. P. Waubay

Peabody. Mrs. P. D. Jr. Webster

Pfister, Mrs. Faris Webster

Younker, Mrs. F. T. Sisseton

VCold, Mrs. H. R. Sisseton

North Dakota State Medical Assn.

Dr. A. E. Spear, Pres.

Dr. Philip G. Arzt, Pres.-Elect
Dr. L. W. Larson, Secy.

Dr. W. W. Wood, Treas.

North Dakota Society of
Obstetrics and Gynecology
Dr. E. H. Boerth, Pres.

Dr. Paul Freise, Vice Pres.

Dr. G. Wilson Hunter, Secy.-T reas.

Minneapolis Academy of Medicine
Dr. Karl W. Anderson, President
Dr. Russell W. Morse, Vice Pres.

Dr. J. C. Miller, Secretary

Dr. Ragnvald S. Ylvisaker, T reasurer

Dr. Henry E. Hoffert, Recorder

ADVISORY COUNCIL

South Dakota State Medical Assn.
Dr. F. S. Howe, Pres.

Dr. H. R. Brown, Pres.-Elect
Dr. J. L. Calene, Vice -Pres.

Dr. Roland G. Mayer, Secy .-Treas.

South Dakota Public Health Assn.
Dr. J. M. Butler, Pres.

Dr. C. E. Sherwood, Vice Pres.

Dr. Gilbert Cottam, Secy .-Treas.

Sioux Valley Medical Assn.

Dr. D. S. Baughman, Pres.

Dr. Will Donahoe, Vice Pres.

Dr. R. H. McBride, Secy.

Dr. Frank Winkler, Treas.

BOARD OF EDITORS

Dr. J. A. Myers, Chairman

Montana State Medical Assn.

Dr. S. A. Cooney, Pres.

Dr. M. A. Shillington, Pres.-Elect
Dr. R. F. Peterson, Secy. -Treas.

Northwestern Pediatric Society
Dr. G. B. Logan, Pres.

Dr. Geo. Kimmel, Vice Pres.

Dr. Northrop Beach, Secy. -Treas.

Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.

Dr. R. C. Webb, Secy.-T reas.

American Student Health Assn.

Dr. Ralph I. Canuteson, Pres.

Dr. Glenadine Snow, Vice Pres.

Dr. G. T. Blydenburgh, Secy.-T reas.

Dr J . O. Arnson
Dr. A. B. Baker
Dr. D. S Baughman
Dr Ruth E. Boynton
Dr. G'lbert Cottam
Dr H S. Diehl
Dr. L. G. Dunlap
Dr Ralph V. Ellis
Dr. W A. Fansler

Dr A R. Foss
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E D. Hitchcock
Dr. R E. Jernstrom
Dr. A. Karsted
Dr. L W. Larson
Dr W H Long
Dr. O. J . Mabec

Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. blenry E. Michelson
Dr. C H Nelson
Dr. N. J . Nessa
Dr Martin Nordland
Dr. J. C. Ohlmacher
Dr. K A. Phelps
Dr. C. E. Sherwood

Dr. M. A. Shillington
Dr J. C. Shirley
Dr. E. Lee Shrader
Dr. E. J Simons
Dr. T . H. Simons
Dr. S. A. Slater
D- W. P. Smith
Dr S. E. Sweitzer

Dr. W. H. Thompson
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H M. N. Wynne
Dr. Thomas Ziskin,

Secretary

LANCET PUBLISHING CO., Publishers, 84 South Tenth Street, Minneapolis 2, Minnesota

Minneapolis, Minn., August, 1946

WASH LESS AFTER SUN-BATHS

Among research workers in the field of biochemistry
it has become recognized as a well established fact that
all manifestations of life, whether normal or morbid, are
accompanied by chemical changes. Until recently, such
an assertion might have been looked upon as too bold,
especially in application to mental disease, but even in
these cases there is now increasing proof of changes as
exemplified by findings in the composition of the blood
and spinal fluid.

The most important contribution of modern biochem-
istry from a practical standpoint has been made in the
fields of vitamin, hormone and antibiotic research. The
importance of the vitamin problem is due to the fact that
esthetic refinement in the culinary art has resulted in a
notable loss of man’s instinct to choose the right food,
while we find that the animal’s instinct remains almost
infallible in this respect. If rats are fed on food de-
ficient in vitamin B they eat their own excrement or
that of other rats which contains this vitamin. If cut off

from even this source of vitamin, they devour each
other and choose the organs that abound in vitamin B,
as the liver. Man, on the other hand, has been obliged
to replace his instinct by science, which has, to be sure,
solved many vitamin problems during the past four
decades but left others to satisfy the ambition of the
zealous investigators of our and later times.

The chemical reactions which give rise to active vita-
min D through radiation is an interesting story. The
sebaceous glands of the skin produce a secretion contain-
ing vitamin D, which is activated by sun radiation on
the surface of the body. This vitamin can be absorbed
through the skin, and therefore a person should not
wash himself too thoroughly after a sun-bath. In ani-
mals the activizing takes place on the hairy tegument.
When the cat licks its fur, or when apes are apparently
hunting for fleas, they are actually satisfying their
hunger for vitamin D, which cannot be reabsorbed
through the thick fur.

A. E. H.

270

August, 1946

271

AS THE LIFE SPAN LENGTHENS

Today we boast of a significant accomplishment of
the medical profession and its allies in the recent length-
ened span of human life. Longevity in the United
States is now surpassed by only a few small populations
in other parts of the world. In this country the life ex-
pectancy at birth was forty years in 1850. It increased
to forty-seven years during the last half of the nineteenth
century. In 1940 it was sixty-three years.

In 1900 there were 7,083,033 (9.32 per cent of the
total population) persons in the United States of fifty-
five years or older, but in 1940 there were 19,591,519
(14.88 per cent of the entire population) persons in this
age period.

The increase in the length of life has been due in
large part to the control of contagious diseases which
formerly were so destructive among young children.
Obviously, many deaths in infancy markedly reduce the
average length of life although many persons attain
senility. For example, with twenty-six years as the aver-
age duration of life in India, a considerable number of
persons live to be old. However, the infant and early
childhood mortality is so high as to reduce the average
to this low level.

Diseases which once were rampant among children
in the United States are now responsible for relatively
few deaths. For example, in Minneapolis (population
492,370) in 1945 there were only 410 deaths among
children from birth through four years of age, and 371
of them occurred during the first year of life (175 of
which were premature births or birth injuries) . Con-
tagious diseases, formerly so destructive, accounted for
relatively few of these deaths in 1945, as follows: Epi-
demic meningitis 4; whooping cough 1; influenza 8;
poliomyelitis 2; pneumonia 51; diarrhea 24. One is im-
pressed by the fact that not one child died from diph-
theria or tuberculosis.

For the years 1942 to 1945 in Minneapolis the average
annual number of births was 12,172. Thus, it is obvious
that the vast majority of children are passing safely
through the first four years of life which was previously
so hazardous. However, in the country as a whole, fur-
ther curbing of controllable diseases among children is
capable of resulting in greater increase in the span of
human life.

The diseases and conditions which cause death after
the age of forty have not responded so well to the efforts
of the medical profession. In fact, among the persons
who have attained this age the expectancy of life is only
one or two years more than it was among persons of
this age fifty years ago. Therefore, achievement in con-
trolling these conditions might result in a further marked
increase in longevity.

With so many persons now living into the seventh,
eighth and ninth decades of life no new condition has
been created, but some situations pertaining to elderly
people have greatly increased in magnitude. A good
example is health problems. Undoubtedly there are far
more older persons suffering from such conditions as
malignancy, heart afflictions, emphysema and tuberculosis
than ever before because there have never formerly been

so many persons in this age period. Indeed, there are
now so many elderly persons in this country that one
occasionally hears it intimated that a considerable num-
ber of physicians may enter the field of geriatrics as a
specialty. It is a question as to whether this situation
will come to pass. In any event, there is now a large
demand on the physicians’ time to care for persons in
the later decades of life. The cordial reception accorded
Geriatric f, the new official journal of the American Geri-
atrics Society, is an indication that physicians everywhere
are seeking information in order to supply this demand.

J. A. M.

STREPTOMYCIN IN TREATMENT OF
TULAREMIA

Considerable variance of opinion has existed until re-
cently as to the most effective therapy for tularemia.

Jackson 1 reports 61 consecutive cases of tularemia
treated successfully with bismuth sodium tartrate admin-
istered intravenously. The solution used is 2 per cent
bismuth sodium tartrate containing 29.6 mg. of bismuth
per cubic centimeter, buffeted with sucrose to isotonicity.

Bell and Kahn 2 reported their results in experimental
tularemia in guinea pigs treated with eleven different
remedies, some containing bismuth. The following were
found to be of no value in this experimental treatment
of tularemia: sulfanilamide, sulfadiazine, sulfamerazine,
acriflavine, metaphen, iodine and bismuth (iodobismitol
with saligenin) , arsenic and bismuth (solution of bis-
muth subgallate and sodium para-aminophenyl arsonate) ,
trivalent arsenic alone (maphersen) , antimony (stibo-
phen) , penicillin, and hyperimmune equine antitularemic
serum.

Foshay and Pasternack 3 report good results in seven
cases of tularemia treated with streptomycin. All re-
sponded promptly to treatment. One case in which treat-
ment was started on the eighth day of the disease was
discharged as cured on the seventeenth day, nine days
after treatment was begun. The authors state that re-
sponse was uniform in character, degree, continuity, and
time of appearance. Foshay and Pasternack used doses
that would probably now be considered suboptimal. The
total dosage used for each of their seven cases varied
from 640,000 units to a maximum of 1,760,000 units.

The Bulletin of the U. S. Army Medical Department
for May, 1946, in a general review of streptomycin, says
this concerning its effects on tularemia, "Present experi-
ence suggests that streptomycin is the most effective
therapeutic agent available for this condition.”

These latter experiences justify the conclusion that,
at present, streptomycin is the most effective therapeutic
agent available for the treatment of tularemia.

T.D.

References

1. Jackson, W. W.: Treatment of Tularemia with Intravenous
Bismuth Sodium Tartrate. Amer. Jour. Med. Sciences,
209: 513, (April) 1945.

2. Bell, J. F., and Kahn, O. B.: Efficacy of Some Drugs and
Biologic Preparations as Therapeutic Agents for Tularemia.
Arch. Internal Med., 75: 155, (March) 1945.

3. Foshay, L., and Pasternack, A. B.: Streptomycin for

Tularemia. J.A.M.A., Feb. 16, 1946.

272

Views lietns

NEWS FROM NORTH DAKOTA

Dr. George F. Campana, North Dakota state health
officer since 1944, resigned June 27. Dr. Leonard Lar-
son, Bismarck, chairman of the state public health ad-
visory council said a successor to Dr. Campana has not
yet been named. Dr. Campana expects to enter private
practice with his brother in Brooklyn, New York.

Officers of the medical staff of St. Luke’s hospital,
Fargo, North Dakota, elected June 18, are Dr. Charles
Fdeilman, president; Dr. C. B. Darner, vice president;
Dr. H. W. Fdawn, secretary; Drs. W. C. Nichols,
W. E. G. Lancaster and V. G. Borland, executive com-
mittee members; Drs. G. Wilson Fdunter and W. A.
Stafne, committee on records, and Drs. A. C. Fortney,
Borland and Fdawn, program committee.

Approximately eighty donators to the Tri-State Hos-
pital fund met at Bowman, North Dakota, June 11, for
the purpose of electing a board of trustees. Named for
one year terms as board of trustee members were L. P.
Dove and M. S. Byrne; two year members are Mrs.
Ray Storer, and J. J. Sedevie; Mrs. Fdarold Brooks was
elected as trustee for a term of three years.

NEWS FROM SOUTH DAKOTA

Dr. Millard C. Hanson, one of the two Boston doc-
tors who have discovered a new medical agent more
powerful in early tests than penicillin, is formerly of
Howard, South Dakota. He was born there in 1898
and left in 1922 to attend the University of Chicago
medical school.

Two Rapid City clinics, the Midwest and the Lemley-
Merryman, merged on July 1. The offices are estab-
lished in the former Lemley Clinic building with com-
plete laboratory and X-ray facilities provided. In the
new medical service are Dr. J. D. Bailey, pediatrics,
Dr. M. P. Merryman, internal medicine, Dr. R. E.
Lemley, genito-urinary, rectal, and skin diseases, Dr.
F. R. Williams, general surgery, orthopedics, and gyne-
cology, and Dr. A. G. Olson, dentistry.

Dr. Joseph Lovering, formerly an assistant surgeon
at the Mayo clinic, became associated July 1 with the
Peabody clinic, Webster, South Dakota, as a surgeon.

Appointment of Dr. Arnold Slaughter, Dallas, Texas,
as dean of the newly expanded four-year medical school
at the University of South Dakota was announced
June 14 by President I. D. Weeks.

At the same time President Weeks announced the
organization of a department of surgery in the medical
school and the appointment of Dr. William R. Cubbins,
Chicago, as head of the department.

Dr. Slaughter, a former Iowan, is at present dean of
students and chairman of the department of physiology
and pharmacology at Southwestern Medical college at
Dallas.

The Journal Lancet

Dr. J. H. Crawford, Jr., and Dr. Mary A. Schmidt
opened offices in the Way-Penney Building, Watertown,
South Dakota, on August 1. Dr. Crawford, a diplomate
of the American Board of Ophthalmology, specializes
in ophthalmology. Dr. Schmidt is a fellow of the Uni-
versity of Minnesota and is a specialist in pediatrics.

NEWS FROM MONTANA

The Montana State Medical association held their
annual meeting July 18-20 in Great Falls, Montana.
News of the meeting will be published in a later issue
of Journal Lancet.

Dr. Frank L. McPhail of Great Falls was elected pres-
ident of the Montana Public Health association at its
two-day session in Helena the early part of June. Dr.
McPhail, who serves as chairman of the maternal child
health committee of the Montana State Medical associa-
tion, succeeded C. G. Manning, Lewistown school super-
intendent.

Dr. William R. Schaffarzick has opened offices in the
Bayles-Nash Clinic, Three Forks, Montana, as a resident
physician and surgeon. He was graduated from the
medical school of Vanderbilt University, Nashville, Ten-
nessee, in 1943, and during the past three years was in
the Armed Forces.

Dr. F. W. Paul and Dr. V. D. Ferree are opening
a clinic in Kalispell, Montana, on August 1. Dr. Paul
served three years in the AAF.

Dr. Frank B. Wisner, who served in the navy, is open-
ing an office in Libby, Montana. He practiced at
Ludlow before the war.

Dr. John C. Wolgamot, Great Falls, Montana, a spe-
cialist in orthopedic surgery, has joined the Great Falls
Clinic. Dr. Wolgamot is a graduate of the University
of Michigan school of medicine and later taught medi-
cine there. He acted as a consultant for the Michigan
state tuberculosis sanitarium.

Dr. H. C. Watts, manager of the Veterans Adminis- I
tration hospital at Fort Harrison, Montana, since 1927,
has been transferred to the VA branch office at San
Francisco.

jbeatlti.

Dr. Thomas F. Quinby, 91, of Minneapolis, died
June 30 after a prolonged illness. Dr. Quinby was the
oldest member of the Hennepin County Medical society,
and senior physician in the county. He was born in
Biddeford, Maine, in 1855.

For two years following his graduation from the col-
lege of physicians and surgeons of Columbia university
in 1878 where he received his M.D. degree, Dr. Quinby
attended the University of Heidelberg, Germany.

Returning to this country in 1880, he settled in Minne-
apolis and for many years played a leading part in civic
enterprises. He served for three years as a city health
inspector, and was elected to the board of education, a
post which he held for twelve years, four of them as
president. He also served for ten years as local surgeon
for the "Soo” line.

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Supposicone is the registered trademark of G. D. Searle & Co., Chicago 80, Illinois

SEARLE

RESEARCH IN THE SERVICE OF MEDICINE

274

The Journal Lancet

Dr. Quinby received a citation from President Wilson
for his services during the influenza epidemic of 1918-19
at the government hospital, Chester, Pennsylvania.

He is survived by his wife and a niece.

Dr. H. L. Koehler, 58, Missoula, Montana, died on
June 8. He was a physician on the staff of the Northern
Pacific hospital in Missoula since January 1944. He was
bom in Wisconsin in 1888.

Dr. Koehler’s medical education was obtained at Loy-
ola university, Chicago. Following his graduation about
1912, he interned in the same city.

In 1937 Dr. Koehler began practice in Poison, Mon-
tana, where he was associated with Dr. John Dimon for
a number of years. He also practiced in Circle and
Glendive and at Three Forks he and Dr. Dimon op-
erated a hospital for the Milwaukee railroad. He was
a veteran of World War I, serving in the medical corps.
He belonged to the American Medical association and
the Western Montana Medical society.

He is survived by his wife, two sons, two daughters,
and a step-son.

Dr. G. W. Glaspel, 81, Grafton, North Dakota, died
June 27. He had practiced there since 1888, and was
the oldest practicing physician in Walsh county. He
was born in Oshawa, Ontario, in 1865.

Dr. Glaspel received his degree from the medical
school of the University of Iowa in 1888. After prac-
ticing for a short time in Hillsboro, North Dakota, he
moved to Grafton to take over the practice of his brother
who had died.

He is survived by a son and a daughter.

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LOCATION FOR PHYSICIAN

PRACTICE FOR SALE

FOR SALE

Retiring from practice. Location and up-to-date office
equipment in business section of International Falls,
Minnesota. No accounts to purchase. By appointment
only. Write Dr. J. H. Drake, Shapira Building, Inter-
national Falls.

FOR SALE

Cambridge-Hindle electrocardiograph, portable model,
in first-class condition. Address Box 844, care of this
office.

NURSE WANTED

Wanted, a nurse with one or two dependents. Small
hospital offers salary, plus bonus, plus living quarters and
meals for nurse and her dependents. Write Box 845,
care of this office.

TECHNICIAN WANTED

Female technician who can do laboratory and x-ray
work, in medical firm situated in lake region of Minne-
sota. Good salary from the start. Address Box 846, care
of this office.

FOR SALE

X-ray — Shockproof 15 M.A. radiographic and fluoro-
scopic unit on mobile floor stand with timer and 12x16
type B screen like new. Will sacrifice. Address Box 847,
care of this office.

FOR SALE

Short wave therapy apparatus, Rose CW2 No. 1640
with electros. Practically new. Phone Bridgeport 8345
in Minneapolis or write Box 848, care of this office.

ASSISTANCE AVAILABLE

Aznoe’s, established in 1896, has available a number
of well trained physicians (diplomates of the specialty
boards, industrial physicians and surgeons, general prac-
titioners, psychiatrists, tuberculosis specialists and resi-
dents). For histories, write Ann Woodward, Aznoe’s-
Woodward Medical Personnel Bureau, 30 North Michi-
gan Ave., Chicago 2, 111.

IMMEDIATE OCCUPANCY

AdMAiistls' AtoHOUHMYiewts

Paba for Tick Fever

Rocky Mountian Spotted Fever or Tick Fever has until re-
cently defied man’s efforts. Now Paba (para-aminobenzoic
acid), a member of the vitamin B-complex group, can be an
effective agent in the treatment of tick and other related fevers
originating with rickettsial organisms.

The International Vitamin Corporation, New York, has
made available for therapeutic use Paba, the only effective agent
so far known in the treatment of tick and typhus fevers. Mem-
bers of the American Typhus Commission in Cairo, Egypt,
made clinical studies of Paba, as did another group in Ledo,
Assam, India. These workers concluded that Paba is decidedly
an effective drug in the treatment of rickettsial diseases.

Wyeth Makes Methionine Available for Clinical Study
Wyeth Incorporated has been the first pharmaceutical firm
in the country to make synthetic dl-methionine available to the
medical profession in sufficient quantity for experimental clin-
ical purposes. Production has still not reached the point where
larger than investigational quantities can be offered through
regular drug channels, but this point is not far off.

The pharmacological evidence which first established the spe-
cific value of methionine in liver damage (fatty infiltration,
cirrhosis and necrosis) due to dietary, toxic and injury factors,
was the work of many scientists, both in America and in Eng-
land. Prominent among these has been the research staff of
the Wyeth Institute of Applied Biochemistry, in Philadelphia.

That liver cirrhosis is not a direct consequence of alcohol
poisoning but may result from malnutrition incident to alcohol
addiction is one of the points brought out by a summary of
the methionine situation just released by Wyeth. While not
necessarily of benefit in liver affections of infectious origin (such

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276

The Journal Lancet

as catarrhal jaundice and Weil’s disease), methionine appears
to be specifically beneficial in remedying liver injury due to
burns, poisoning by carbon tetrachloride, chloroform, TNT,
and other industrial and anesthetic chemicals, and in general
all types of liver damage due to faulty nutrition. The latter is
said to include eclampsia.

Ayerst Introduces Fluoride Tablets for Dental Use

Ayerst, McKenna & Harrison Limited, Division of American
Home Products, Inc., New York, has introduced "Enziflur”
Tablets containing calcium fluoride with vitamins C and D.

Various investigators in recent years have reported that fluor-
ine in the drinking water of certain midwestern communities
appeared to inhibit the development of dental caries among
children of such areas. In clinical studies, Ayerst found that
tablets of calcium fluoride would produce the same result, and
that the addition of vitamins C and D would materially en-
hance the action of the fluoride.

"Enziflur” Tablets are available in bottles of 30 and 100
tablets. Each tablet provides Calcium Fluoride, 2.0 mg.; Vita-
min C (ascorbic acid), 30.0 mg., and Vitamin D (irradiated
ergosterol) , 400 I.U. (U.S.P. XII). One tablet daily supplies
the optimal amount of calcium fluoride for the prevention of
dental caries.

Radio Series Dedicated to Medical Profession

Development of wider public understanding and appreciation
of the contribution made by the medical profession and by med-
ical research to the world’s health and welfare is the objective
of a new series of radio programs on the Columbia Broadcasting
System heard every Tuesday at 7:30 P.M., Central Standard
Time.

The half-hour program, known as "Encore Theater,” pre-
sents radio dramatizations of famous films, novels, and biog-
raphies, dealing with medicine’s immortals, as well as with the
work, achievements and struggles of thousands of members of
the medical profession who, although by-passed by fame, daily
are making substantial contributions to the prevention and cure
of disease, often at great personal sacrifice. Sponsor of the pro-
gram is Schenley Laboratories, Inc., which for the past two
years has sponsored a somewhat similar program dedicated to
the medical profession, “The Doctor Fights.”

The programs are designed to underline the scientific achieve-
ments of the medical profession, while stressing the human
warmth and sympathy which often prompts members of the
profession to sacrifice health and even personal life in order to
serve others.

Repair Service for Hospitals and Doctors
Experience and concentration along a specialized line lead to
dependable service and it would be difficult to find any business
in which this is more certain to be true than in repairing, re-
plating, and renewing instruments and equipment employed by
physicians. For thirteen years Louis Seekon played an important
part in the repair and replacement division of a company sup-
plying cardiographs, sterilizers, calorimeters and operating equip-
ment. Possessed of the background and facilities to engage in
such work on "his own” he has opened a modern shop at

322 S. 6th St., Minneapolis, called the Twin City Hospital and
Physicians Repair Service, and handles jobs of all sorts in this
field, emphasizing a willingness to quote the price of repairs and
to give an estimate of the time required. Round-the-clock serv-
ice is another feature.

Promise Large-Scale Streptomycin Output
Significant progress toward large-scale output of streptomycin
is reported by Merck & Co., Inc., at Rahway, New Jersey, in
its annual report.

Investigations conducted by the firm show that the drug is
effective in tularemia or rabbit fever, certain infections of the
kidney and bladder, and certain wound infections unaffected by
other treatments. It also has proved of value in treating tuber-
culosis and undulant fever. Last year the firm began construc-
tion of a group of buildings for large-scale production of the
mold chemical at its Elkton, Virginia, plant.

Medical Literature for the Veteran Physician
A special compilation of informative literature on recent de-
velopments in endocrinology is being presented to each physi-
cian returning from service in the armed forces during the war.
Publisher of this literature is the Schering Corporation, of
Bloomfield and Union, New Jersey, manufacturers of endocrine,
diagnostic and other pharmaceutical preparations.

The "Welcome Home” collection supplies information de-
signed to help the military doctor bring himself up-to-date in
civilian practice. It contains a copy of "Sex Endocrinology,”
the illustrated 96-page volume covering the physiology, chem-
istry and rationale of hormones in modern therapeutics. A
"handy index” provides in brief outline form for the physician
readily accessible and concise summaries on treatment and dos-
age of endocrine products. The accompanying copy of the
Schering "Handbook” supplies to the physician technical infor-
mation and product data on Schering pharmaceuticals.

Free Case History Forms Offered by Ar-Ex Cosmetics

The importance of comprehensive history taking in diagnosis
has been stressed by every clinician and diagnostician. Too
often symptoms of obscure etiology remain undiagnosed for
years because the case history failed to bring the significant
cause to light. In its contacts with physicians, the Professional
Service Department of Ar-Ex Cosmetics, Inc., has frequently
heard the desire for more adequate case history forms. As a
result, expert clinicians were consulted in the development of
a case history form that would serve the purpose of both the
specialist and the general practitioner. In preparing the form,
two thoughts were kept in mind: (1) to make it as compre-
hensive as possible to reveal both obscure and obvious causa-
tive factors; (2) to make it concise enough to be of value to
the busy physician. Though time and usage will undoubtedly
improve the present form, many physicians have pronounced the
new Ar-Ex Cosmetics case history form as the most compre-
hensive and revealing form of which they know.

Supplies of the forms are now being distributed to interested
physicians without cost or obligation on request to the profes-
sional service department of Ar-Ex Cosmetics, Inc., 1036 W.
Van Buren Street, Chicago 7, Illinois.

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Rochester, Minnesota

Sulfonamides and Antibiotics in the* Prevention and
Treatment of Infectious Diseases

Wesley W. Spink, M.D.f
Minneapolis, Minnesota

Advances in the prevention and treatment of infec-
XJLtious diseases have been remarkably rapid in recent
years and for this reason it becomes important to review
occasionally the status of various specific agents used in
the management of infections. This applies especially
to the sulfonamides and to the antibiotics. This subject
is of importance to physicians charged with the respon-
sibility of the health of university and college students.
The following remarks, then, would apply particularly
to clinical conditions and problems of infectious diseases
as they confront the physician in the student health
services. At the University of Minnesota Hospitals my
associates and I have been particularly fortunate in carry-
ing out clinical observations on the Student Health Serv-
ice under the direction of Dr. Ruth Boynton.

Present Status of the Sulfonamides in the
Treatment of Infection

While penicillin has supplanted the use of the sulfona-
mides in the treatment of a large number of infections,
and rightfully so, there still remain some clinical condi-
tions where sulfonamide therapy is indicated. At this
point I should like to discuss the systemic and local use
of the sulfonamides.

Systemic Use of the Sulfonamides
By systemic use is meant the administration of the
sulfonamides by either parenteral or oral routes.

Presented at the annual meeting of the American Student
Health Association, May 7-9, 1946, Minneapolis, Minnesota.

f Professor of Medicine, University of Minnesota Medical
School and Hospitals, Minneapolis.

Urinary tract infections. Urinary tract infections are
frequently caused by gram-negative bacilli which are
highly resistant to the action of penicillin. This includes
the following species: Escherichia coli , Proteus vulgaris,
Pseudomonas pyocyaneus, and Aerobacter aero genes. On
the other hand, some strains in the foregoing species may
be highly resistant to the bacteriostatic action of the sul-
fonamides. Other causative micro-organisms of infec-
tions of the urinary tract include Streptococcus viridans
and Streptococcus faecalis and, occasionally, nonhemo-
lytic or gamma streptococci. Again, there are some strains
within these species that are not only resistant to penicil-
lin but resistant to sulfonamides as well. One of the out-
standing features related to the treatment of urinary
tract infections with the sulfonamides is that relatively
small doses of the drugs are necessary. At the present
time at the University of Minnesota Hospitals, sulfadia-
zine is the drug of choice. Thus sulfadiazine, in common
with others, is concentrated and excreted through the
kidneys, resulting in high levels of the drug in the uri-
nary tract. Many cases may be satisfactorily treated by
giving 0.5 gram three or four times a day. In some in-
stances it has been desirable to use 1 gram three to four
times a day. Rarely is it necessary to use the material
parenterally. When the smaller doses of sulfadiazine are
employed it is not necessary in the great majority of cases
to give an alkali in order to maintain an alkaline reaction
in the urine. However, an adequate intake of fluid is
always recommended.

277

278

The Journal Lancet

Meningitis. Highly satisfactory clinical results have
been obtained in the treatment of meningococcic menin-
gitis with the sulfonamides. While penicillin is also effec-
tive, in most cases we prefer to use sulfadiazine because
the drug can be administered either orally or parenterally
with adequate concentrations appearing in the cerebro-
spinal fluid. If the patient can take sulfadiazine by
mouth, an initial dose of 4 gm. is given and then 1 gm.
every four hours. The object is to maintain a blood con-
centration of at least 5 mgm. per 100 cc. If the con-
dition of the patient does not permit the administration
of the drug orally, a solution of sodium sulfadiazine is
injected intravenously as an initial dose of 3 to 4 gm.
of sodium sulfadiazine contained in 500 cc. of physio-
logical saline solution, and then 1 gm. of sodium sulfa-
diazine in 100 cc. of saline solution is administered every
six to eight hours. As soon as possible thereafter, the
patient is encouraged to take sulfadiazine by mouth.

Within twenty-four hours after the initiation of chemo-
therapy the cerebrospinal fluid will be sterile. Treatment
with sulfadiazine is usually carried out for at least seven
to eight days and then discontinued if the cerebrospinal
fluid findings are normal. In desperate cases of meningo-
coccic meningitis some authorities also recommend the
use of antimeningococcic serum in addition to sulfadia-
zine. We have utilized the serum only on extremely rare
occasions. Penicillin has also been administered in com-
bination with sulfadiazine in the treatment of meningo-
coccic meningitis, particularly in seriously ill patients.
There is certainly no contraindication for combining
therapy but it has been extremely difficult to evaluate
clinical results under these circumstances. Because peni-
cillin penetrates the blood-brain barrier eradically when
injected intramuscularly or intravenously resulting in
little or no material to be found in the cerebrospinal
fluid, it is desirable to give a solution of penicillin intra-
thecally as will be described shortly.1 Either the sodium
or calcium salt of penicillin may be injected intramuscu-
larly in doses of 20,000 to 30,000 units every two to
three hours.

While meningitis due to Haemophilus influenzae,
type B, is rarely the cause of meningitis in the age group
found on a college or university student health service,
it is a frequent cause of meningitis in infants and young
children. Sulfadiazine and specific antiserum are indi-
cated in the treatment of this type of meningitis. While
some strains of Haemophilus influenzae are sensitive to
penicillin, many strains are highly resistant. For this rea-
son, penicillin is not recommended as a routine in the
treatment of this type of meningitis.

Both sulfadiazine and penicillin are indicated in the
treatment of pneumococcic meningitis. It is to be re-
called that pneumococcic meningitis is an extremely seri-
ous disease. The mortality rate of untreated cases is
around 100 per cent. At the University of Minnesota
Hospitals, the mortality rate following the introduction
of treatment with the sulfonamides has been slightly
more than 60 per cent. It has been stated that the mor-
tality rate of pneumococcic meningitis in all age groups
is around 50 per cent following the use of penicillin. -
At the University of Minnesota Hospitals experience

with a combination of sulfadiazine and penicillin has
resulted in the mortality rates of less than 25 per cent.3
Obviously, there are many factors affecting mortality
rates besides specific therapy. These include the nutri-
tional status of the patient; the age of the patient; the
duration of the disease; the type of pneumococcus re-
sponsible for the disease; and the successful surgical
eradication of foci of infection. Sulfadiazine should be
given in doses which will maintain a blood concentration
of at least 10 mgm. per 100 cc. Sulfadiazine may be
given orally or, if necessary, the sodium salt may be ad-
ministered parenterally. Neither sulfadiazine nor sodium
sulfadiazine should be injected into the subarachnoid
space.

The sodium or calcium salt of penicillin is given par-
enterally in doses of 30,000 to 40,000 units every two
hours during the initial phases of the illness. During
the same phase, a lumbar puncture is performed every
twelve hours and at least 10 cc. of cerebrospinal fluid is
removed and replaced with 10 cc. of physiological saline
solution containing 10,000 units of the sodium salt of
penicillin. As the patient improves, the penicillin may be
introduced every twenty-four hours and, concurrently,
the doses being given intramuscularly may be reduced.
Treatment should be continued as outlined until the
cerebrospinal fluid remains sterile and the concentration
of the sugar approaches normal. Treatment with peni-
cillin by both intrathecal and intramuscular routes in
most instances may be discontinued at the end of two
weeks, but sulfadiazine should be given orally in doses
of 1 gm. every four to six hours for at least two more
weeks. During convalescence the patient should be ob-
served closely for any signs of a relapse. It has not been
necessary to use type specific antipneumococcic serum in
conjunction with penicillin or sulfadiazine. The treat-
ment of staphylococcic meningitis is essentially the same
as that outlined for pneumococcic meningitis and, in our
experience, satisfactory results have been obtained.

Pneumonia. While sulfadiazine has proved to be ef-
fective in the treatment of pneumonia due to the various
types of pneumococci, penicillin is the drug of choice.
This also applies to pneumonia due to hemolytic strep-
tococci.

Bacillary Dysentery. Sulfadiazine is recommended for
the treatment of dysentery due to the Shigella group of
organisms. Therapy with sulfadiazine is usually com-
bined with one of the sulfonamides that is poorly ab-
sorbed from the intestinal tract such as sulfasuxidine.

Nasal pharyngitis and tonsillitis due to Group A hem-
otlytic streptococci. Physicians responsible for the health
of university and college students are frequently con-
cerned with the problem of upper respiratory infections
due to group A hemolytic streptococci. This also in-
cludes complications of streptococcic respiratory disease
such as acute sinusitis and otitis media. It is now gen-
erally agreed that the sulfonamides do not appreciably
alter the clinical course of patients having nasal pharyn-
gitis and tonsillitis. Clinical observations on the student
health service by Dr. Ruth Boynton and her associates
at the University of Minnesota have revealed that the
duration of the illness in the treated group was the same

September, 1946

279

as that of the untreated group of control patients. There
was no difference in the incidence of complications be-
tween the two groups. This has been the experience of
others when dealing with a group of healthy young
adults in a good state of nutrition who became acutely
ill with a streptococcic upper respiratory infection.4 How-
ever, in children, it would appear that treatment with
sulfadiazine has reduced the incidence of complications
from these streptococcic respiratory infections. It is also
generally agreed that the clinical course of scarlet fever
is not appreciably altered by sulfonamide therapy,
although, again, suppurative complications may be re-
duced. The administration of a sulfonamide to indi-
viduals with streptococcic sore throats will not reduce
the incidence of acute rheumatic fever.4

Local Use of the Sulfonamides
The sulfonamides, particularly sulfanilamide and sul-
fathiazole, have been extensively used as topical agents
in the treatment of infection. With but rare exceptions,
most authorities are not in favor of using the sulfona-
mides as topical agents. This has been largely due to
the fact that an appreciable number of patients have
been sensitized to the drug in this manner, and also
because the clinical results have not been too encour-
aging. The spread of an infection from a local area may
be prevented by utilizing the sulfonamides systemically.
Furthermore, most serious suppurative lesions are due
to the gram-positive group of organisms. Under these
conditions, the local application of penicillin may be more
advantageously utilized since the action of penicillin is
not inhibited by the presence of necrotic tissue and
exudate.

Present Status of the Sulfonamides in the
Prevention of Infectious Diseases
Systemic. Sulfonamides, especially sulfadiazine, have
been widely used in the prevention of acute respiratory
infection. It has been estimated that group A hemolytic
streptococci are responsible for approximately 20 per
cent of all upper respiratory tract infections. In time
of war, the incidence among fresh recruits is frequently
much higher, and experience in World War II empha-
sized the high attack rate in recently inducted military
personnel. Although upper respiratory infections due to
hemolytic streptococci are for the most part relatively
benign infections, the late nonsuppurative complications
resulting from these diseases may be disastrous.

The most important nonsuppurative complication is
acute rheumatic fever. During the last war, the attack
rate of acute rheumatic fever reached serious proportions
among military personnel in all branches of the services.
It was soon appreciated that the sulfonamides did not
prevent the incidence of rheumatic fever after the tissues
had been invaded by group A hemolytic streptococci.
In an effort to prevent the invasion of the pharynx by
streptococci, several programs of sulfonamide prophy-
laxis were carried out among healthy groups. ’’6’7,8 The
procedure was to give % gm. to 1 gm. of sulfadiazine
twice daily. It would appear that such a procedure was
associated with a drop in the attack rate of streptococcic
respiratory infections and a reduction in the incidence of
acute rheumatic fever. Captain T. J. Carter,9 Chief of

the Division of Preventive Medicine, Bureau of Medi-
cine and Surgery, United States Navy, has stated that
in 1943 mass chemoprophylaxis involving a million men
was undertaken in selected stations on a controlled basis,
the result of which was very successful. "At one station
the rate of admission for scarlet fever varied from 63.5
per thousand to 171.6 per thousand during the observa-
tion period before the use of sulfadiazine. Following the
institution of the prophylaxis, the rate fell to zero within
two weeks. Tonsillitis at this same station fell from
426 per thousand to 46 per thousand. Rheumatic fever,
the most serious of the infections associated with the
streptococcus organism because of the heart involve-
ments, was reduced from 87 per thousand to zero within
four weeks.” Captain Carter estimated that this pro-
gram saved over a million man-days for medical per-
sonnel, and between 50 and 100 million dollars.

However, it soon became apparent that this type of
chemoprophylaxis induced the appearance of invasive
strains of group A hemolytic streptococci which were
highly resistant to the bacteriostatic action of sulfadia-
zine. These sulfonamide-resistant strains became widely
disseminated and caused disease in epidemic form.19’11
Fortunately, these strains were still susceptible to thera-
peutic concentrations of penicillin. If penicillin had not
become available, there is every reason to believe that
serious and disastrous consequences would have followed
this mass chemoprophylaxis program due to the dissem-
ination of sulfonamide-resistant streptococci. The sig-
nificance of this statement is illustrated by the report of
Allman.1- An epidemic of scarlet fever due to a strain
of group A type 17, hemolytic streptococci included
5,640 cases. This particular strain was highly resistant
to sulfadiazine. In fact, experiments in vitro revealed
that the strain grew in the presence of 125 mgm. per
100 cc. of sulfadiazine. Obviously, any complications
arising in this group of cases of scarlet fever would not
be benefited by sulfonamide therapy. However, there
were 511 cases of otitis media, 60 cases of acute mas-
toiditis, and two of meningitis. The individuals having
these complications were treated with penicillin and in
some cases a combination of surgery and penicillin was
employed. No deaths occurred.

In view of the experience of chemoprophylaxis in mili-
tary personnel, the use of small doses of sulfonamides
in a large segment of a civilian population should not
be encouraged. The procedure may not only be asso-
ciated with the development of sulfonamide-resistant
strains of bacteria, but, also, an appreciable number of
individuals may become sensitized to the drugs or de-
velop serious toxic reactions. One group of individuals
who may be benefited by such a chemoprophylactic
program includes children who have had one or more
attacks of acute rheumatic fever. It is now well estab-
lished that recurrent attacks of acute rheumatic fever in
children may be precipitated by upper respiratory infec-
tions due to hemolytic streptococci. Several qualified
groups of investigators have shown that these recurrent
attacks may be prevented in children if they are given
small daily doses of a sulfonamide which will prevent the
onset of upper respiratory infection.13’14’1'0’16’17 It is

280

The Journal Lancet

becoming more apparent that this prophylactic program
should be carried out not only during those months when
respiratory infections are most prevalent but all during
the year. The procedure is to give '/2 gm. to 1 gm. of
sulfadiazine daily. Fortunately, the toxic reactions fol-
lowing such a procedure have been relatively small. In
general, children tolerate the sulfonamides much better
than adults. There are no indications that the use of
these small amounts of sulfadiazine are detrimental to
a growing child. If a child has had one or more attacks
of rheumatic fever, it is desirable that he should receive
sulfonamides during those years when rheumatic fever
is most likely to occur, namely, between the ages of
five and fourteen years.

Meningococcic meningitis. The meningococcus is
highly susceptible to the antibacterial action of the sul-
fonamides, and in contrast to the gonococcus, very few
strains of meningococci occurring in epidemics have been
shown to be resistant to the drug. There is no doubt
that when meningitis breaks out in a closely knit group,
a program of sulfonamide prophylaxis should be invoked
immediately among the healthy contacts.18,19 Under
these circumstances, an epidemic may be promptly con-
trolled.

Sulfonamide Prophylaxis Postoperatively

At the University of Minnesota Hospitals the sulfona-
mides have been used postoperatively by Dr. O. H.
Wangensteen and his staff in selected patients. In many
instances, it has been necessary to place an indwelling
catheter into the urinary bladder and, in order to pre-
vent the development of cystitis as a result of this pro-
cedure, small daily doses of sulfadiazine have been given
parenterally. In the majority of instances, when an in-
dwelling catheter is used in the urinary bladder, prophy-
lactic treatment with a sulfonamide is indicated.

Prophylactic Use of Sulfonamides by
Local Application

There has been a tendency in several quarters to use
the sulfonamides locally in traumatic and surgical wounds
for the prevention of infection. In fact, this was the
recommended procedure for a time in the Armed Forces
of the United States. In general, this procedure has
been abandoned. Preparations of the sulfonamides in
sprays, gums and gargles have also been used for pro-
phylactic purposes but this indiscriminate use of the
drugs should be discouraged. Such a procedure has very
questionable value, and is one way of developing sulfona-
mide-resistant organisms and inducing sensitivity in in-
dividuals to the drugs.

Antibiotics

Waksman 20 has defined an antibiotic as a chemical
substance of microbial origin which inhibits the growth
or the metabolic activities of bacteria and other micro-
organisms. While this antagonistic relationship has in-
terested bacteriologists for many years, the application
of this knowledge for clinical purposes is only a recent
development. Considerable impetus was given to this
field of endeavor by the fundamental observations of
Dubos.21,22 Tyrothricin, produced by Bacillus brevis,
was studied by Dubos and found to be a complex sub-
stance containing tyrocidine and gramicidin. From a clin-

ical point of view, the crude preparation, tyrothricin, has
been used for topical application in the treatment of local
infection. The material cannot be used orally or paren-
terally because of its toxic properties. Tyrothricin is not
inhibited by necrotic material and exudate, and it is most
effective against gram-positive organisms. Therefore,
this material has only limited clinical application. It also
has been used extensively in veterinary medicine. The
dental profession has used it for topical application in
the mouth for prophylactic and therapeutic purposes.

Penicillin

Time does not permit a comprehensive discussion rela-
tive to the clinical use of penicillin. It is desirous, how-
ever, to review briefly some of the recent developments
pertaining to the production of penicillin; methods of
administering penicillin; and the use of penicillin in the
treatment of clinical conditions that are more likely to
be encountered on a student’s health service.

While, as far as is known, penicillin has not been syn-
thesized chemically, considerable information is now
available concerning the chemistry of penicillin. This has
some bearing on the clinical use of penicillin. In the
commercial preparation of penicillin, it has now become
apparent that there are now several antibiotics of the
penicillin class, notably penicillin F, G, X and K. These
penicillins differ chemically and biologically. Penicillins
now available for clinical use very likely contain a mix-
ture of these different fractions.*

Methods of Administering Penicillin

There are several methods whereby penicillin may be
introduced into the body. For the more severe infections,
it is desirable to introduce either the calcium or sodium
salt of penicillin parenterally. Most severe infections can
be satisfactorily treated by the intermittent intramuscular
route. Since penicillin is excreted relatively rapidly from
the body, frequent injections should be given. During
the initial stages of the more severe infections, it is de-
sirable to give an injection every two hours. Solutions
of penicillin may also be given by a continuous intra-
muscular method. According to Hirsh and Dowling,23
200,000 units of penicillin may be given in twenty-four
hours (8,333 units per hour) by the continuous intra-
muscular method which will maintain a therapeutically
effective blood level 96 per cent of the time. If 25,000

*Since this paper was presented, an important communication
has appeared in the Journal of the American Medical Associa-
tion, Volume 131, page 271, May 25, 1946, on "The Chang-
ing Character of Commercial Penicillin,” which is a joint state-
ment by the Committee on Medical Research, the United States
Health Service and the Food and Drug Administration. It is
pointed out that commercial penicillin is not a single substance.
Those substances that have been identified are penicillins G, X,
F, and K. The relative amounts of these several penicillins may
very well vary from time to time and in recent months it would
appear that some commercial penicillins contain a significant
proportion of penicillin K. Penicillin K is relatively ineffective
against several infections and its inefficiency when used in the
treatment of infections is probably related to the fact that, un-
like G, X and F, it is rapidly destroyed in the body. These
authorities point out further that in the purification of com-
mercial penicillin it is possible that there has been a decrease in
"impurities” which may possibly effect the therapeutic activity.
It is now recognized that penicillin K is relatively ineffective
against syphilis which is reflected in the relapse rate of patients
treated with the more purified commercial penicillins.

September, 1946

281

units of penicillin are injected intramuscularly every
three hours similar concentrations occur only 80 per cent
of the time. While moderate pain may be associated in
some patients with this type of injection, this can be
avoided by changing the site of the injection every
twenty-four to ninety-six hours and the use of procaine
may also alleviate the pain. It is unnecessary to use the
intermittent intravenous method in the treatment of in-
fections. The continuous intravenous drip method may
perhaps be profitably utilized in the treatment of patients
with subacute bacterial endocarditis. According to Loewe
and his associates,24 more superior serum levels are main-
tained by the continuous intravenous method than by the
continuous intramuscular method. At the University of
Minnesota Hospitals the vast majority of patients are
treated by the intermittent intramuscular method.

In order to delay absorption of penicillin from the
muscles after injection, various methods have been pro-
posed to delay absorption from these sites. An effective
method is that devised by Romansky and Rittman,25’26
in which calcium penicillin suspended in beeswax and
peanut oil is injected intramuscularly. In this manner,
there is a slow release of penicillin from the tissue which
is prolonged over a period of several hours. At the pres-
ent time, the material available for clinical use consists
of 300,000 units of calcium penicillin 4.8 per cent bees-
wax (by weight) and peanut oil contained in 1 cc.
According to Romansky and Rittman 27 a single intra-
muscular injection of this material will maintain effective
blood levels for twenty-four hours and penicillin will be
detected in the urine for three days thereafter. Kirby
and his group,28 however, found that there are wide
individual variations in absorption and excretion when
penicillin in beeswax and peanut oil was injected intra-
muscularly. In 69 per cent of the patients, levels were
present for no longer than twelve hours. Leifer, Mark
and Kirby 29 point out that larger amounts of penicillin
must be given in beeswax and oil preparations than when
multiple injections of penicillin in saline solution are
used. There appeared to be no doubt that the single in-
jection of penicillin in beeswax and oil was effective in
the vast majority of cases of acute gonococcic urethritis.
For the present, at the University of Minnesota Hos-
pitals, the more severe infections are not being treated
with this preparation but by the multiple intramuscular
injections of penicillin in saline solution.

Solutions of penicillin may also be given orally. The
careful observations of McDermott and his associates 30
would indicate that penicillin given orally is therapeu-
tically effective, provided five times the amount is given
orally as would be injected parenterally. Contrary to
many statements, the acidity of the gastric contents does
not appear to influence materially the absorption of peni-
cillin. Therefore, it is not necessary to give antacids with
penicillin. The important feature is to administer the
material on a fastirtg stomach, that is, before meals.
For the present, it is probably not desirable to treat
severe infections by the oral route. There are now prep-
arations of commercial penicillin on the market for oral
use such as troches and buffered tablets. These are not

indicated for use in the initial stages, at least, of severe
infections.

Solutions of penicillin may also be injected into the
serous cavities and, as has already been pointed out, in
the treatment of suppurative meningitis, it is necessary to
inject penicillin into the subarachnoid space. Penicillin
in any form should not be instilled within the rectum for
clinical purposes. The amount of material absorbed is
totally ineffective.

Penicillin has also been utilized by aerosolization 31-32
for the treatment of upper respiratory tract infections
such as bronchial asthma, chronic bronchitis, bronchiecta-
sis, and lung abscess. Aerosols have been defined by
Segal and Ryder 32 as "suspensions of liquids or solids
in air or oxygen.” This method has been used at the
University of Minnesota Hospitals by my associate, Dr.
Wendell H. Hall, utilizing the BLB oxygen mask and
bubbling oxygen through an aqueous solution of peni-
cillin. While the number of cases treated has been small,
the results have not been too encouraging. There is no
doubt that the procedure, though it has its limitations,
has some indications in patients with the foregoing con-
ditions. Segal and Ryder 32 feel that the method is an
ideal therapeutic approach for the preoperative and post-
operative treatment of patients with bronchiectasis and
a prolonged course of treatment may be effective in
some cases of lung abscess.

Clinical Indications for Penicillin

It is timely to discuss briefly the use of penicillin in
such streptococcic diseases as nasopharyngitis, tonsillitis,
sinusitis, otitis media and scarlet fever. As pointed out
previously, the average patient with tonsillitis or naso-
pharyngitis on a student health service recovers with but
rare suppurative complications. Penicillin should only be
utilized for the more acutely and severely ill individuals.
Under these conditions, the systemic use of penicillin is
followed by objective improvement within a relatively
few hours. It is important that treatment be continued
for at least five to seven days since, if treatment is dis-
continued within forty-eight to seventy-two hours, there
may be clinical relapses with complications. During the
acute stages of the illness, penicillin may be given par-
enterally in doses of 20,000 units every two or three
hours and then as the patient recovers, penicillin may be
administered orally in doses of 40,000 units four times
a day. In acutely ill patients with scarlet fever, peni-
cillin is probably effective against the suppurative stage
of the disease but does not appear to influence the tox-
emia. Therefore, it is necessary in some instances to use
antitoxin, as contained in convalescent human serum, in
combination with penicillin. Penicillin has been found
to be effective in the treatment of otitis media, and also
in early cases of acute mastoiditis. In the treatment of
meningitis due to group A hemolytic streptococci, it is
desirable to use the material parenterally as well as
intrathecally.

Penicillin is the most effective agent used for fuso-
spirochetal disease or Vincent’s infection. The material
may be given parenterally or orally and usually it is only
necessary to treat the patient for forty-eight to seventy-
two hours.

282

The Journal Lancet

Penicillin should be used in the treatment of pneumo-
coccic and streptococcic pneumonia. Doses of 20,000
units given intramuscularly every three hours are effec-
tive and treatment should be continued for three to five
days. Penicillin may be used parenterally for the first
forty-eight hours, and then as the patient improves and
the temperature becomes normal, 40,000 units of peni-
cillin may be given orally four times a day for three
more days.

The foregoing constitutes some of the more frequent
infections seen on a student health service and, as point-
ed out before, it is not necessary at this time to review
the clinical indications for penicillin.

Prophylactic Use of Penicillin

Penicillin has not been evaluated for prophylactic pur-
poses as extensively as the sulfonamides. One of the
problems in infectious diseases relating to upper respira-
tory tract infections is the human carrier of group A
hemolytic streptococci. Hamburger and his associates 33
have pointed out that the dangerous carrier is the indi-
vidual having hemolytic streptococci in nasal cultures.
He has recommended the eradication of streptococci
from the nasopharynx of these carriers by the daily use
of a single intramuscular injection of penicillin in bees-
wax and peanut oil.'54 Penicillin is also indicated prophy-
lactically in individuals with acquired or congenital car-
diac lesions who are to have tooth extractions or tonsillec-
tomies. In this manner, the onset of subacute bacterial
endocarditis may be prevented by giving an injection im-
mediately before the surgical procedure and then mul-
tiple doses by mouth for a day or two after operation.

Streptomycin

In 1944, Waksman and his associates 3o found that
streptomycin produced by the actinomycetes 5. griseus
was antagonistic for gram-positive and gram-negative
bacteria. Streptomycin is now being evaluated clinically
and the clinical indications for streptomycin must await
the results of these studies. Like penicillin, streptomycin
is highly soluble in aqueous solutions. While the ma-
terial may be ingested orally, relatively little of the ma-
terial is absorbed and, therefore, for systemic infections,
the material should be injected parenterally. Streptomy-
cin is largely excreted through the kidneys and the rate
of excretion is similar to that of penicillin. Therefore,
the material is injected parenterally every three to four
hours. Following parenteral injections, small amounts of
streptomycin do appear in the spinal fluid. But in the
treatment of meningitis it becomes necessary to inject
the material intrathecally. Streptomycin is more toxic
than penicillin, but less so than the sulfonamides, and
the toxicity, in part at least, may be related to impuri-
ties in the material.

Streptomycin has been found to be quite effective in
the treatment of tularemia. The drug has also been
found to be effective following parenteral injection in
the treatment of certain gram-negative bacillary urinary
tract infections , particularly in instances where the organ-
isms have been found to be highly resistant to both the
sulfonamides and to penicillin. Highly encouraging re-
sults have also been obtained in the treatment of menin-
gitis due to Haemophilus influenzae, type B. Thus far,

the clinical results in brucellosis have not been too en-
couraging, but further studies are necessary before final
conclusions can be drawn. Experimentally, streptomycin
has been found to be effective against tuberculosis.30
In human patients, it would appear that treatment with
large amounts of streptomycin over a relatively long
period of time have been effective in some types of extra-
pulmonary tuberculous lesions. The precise role of strep-
tomycin in the therapy of tuberculosis must await further
development. In experimental animals, streptomycin has
been found to be protective against infections with Hae-
mophilus pertussis 37

From the foregoing it would appear that another anti-
bacterial agent has been made available, especially for
gram-negative bacterial infections. While streptomycin
is not yet available for general use, there are indications
that in the near future the material will be commercially
available.

Bibliography

1. Kinsman, J. M., and D’AIonzo, C. A.: The Penetration
of Penicillin Through Normal and Inflamed Meninges. New
Eng. J. Med., 234: 459, 1946.

2. Keefer, C. S.: Penicillin — Its Present Status in Infec-

tions. Am. J. M. Sc., 210: 147, 1945.

3. Hall, W. H., Alden, J., Burt, G. M., and Spink, W.
W.: The Treatment of Pneumococcic and Staphylococcic Men-
ingitis with Penicillin and Sulfonamides: Report of 20 Cases.
Minnesota Medicine, 29: 553, 1946.

4. Spink, W. W., Rantz, L. A., Boisvert, P., and Cogge-

shall, H.: Sulfadiazine and Penicillin for Hemolytic Strepto-

coccus Infections of the Upper Respiratory Tract. Arch. Int.
Med., 77: 260, 1946.

5. The Prevention of Respiratory Tract Bacterial Infections
by Sulfadiazine Prophylaxis in the United States Navy. Epi-
demiology Unit No. 22: NAVMED 284, Bureau of Medicine
and Surgery, Navy Department, Washington, D. C.

6. Watson, R. F., Schwentker, F. F., Fetherston, J. E., and

Rothbord, S.: Sulfadiazine Prophylaxis in an Epidemic of

Scarlet Fever, J.A.M.A., 122: 730, 1943.

7. Holbrook, W. P.: The Army Air Forces Rheumatic

Fever Control Program. J.A.M.A., 126: 84, 1944.

8. A. F. Coburn: The Prevention of Respiratory Tract Bac-
terial Infections by Sulfadiazine Prophylaxis in the United
States Navy. J.A.M.A., 126: 88, 1944.

9. Mass Chemoprophylaxis at all Naval Training Stations.
J.A.M.A., 127: 96, 1945.

10. Sulfadiazine Resistant Strains of Beta Hemolytic Strep-

tococci: Appearance During the Course of Sulfadiazine Prophy-
laxis at a Large Naval Training Center. Epidemiology Unit
No. 22. J.A.M.A., 129:921, 1945.

11. Damrosch, D. S.: Chemoprophylaxis and Sulfonamide

Resistant Streptococci. J A M. A., 130: 124, 1946.

12. Allman, C. H.: Penicillin in Otology: Its Use in 511
Cases of Otitis Media and 74 Cases of Mastoiditis. J.A.M.A.,
129:109, 1945.

13. Coburn, A. F., and Moore, L. V.: Follow-Up Report on
Rheumatic Subjects Treated with Sulfanilamide. J.A.M.A.,
117: 176, 1941.

14. Kuttner, A. G.: Prevention of Rheumatic Recurrences:

Discussion of Various Measures Now Being Used. N. Y.
State J. of Med., 43: 1941, 1943.

15. Thomas, C. B.: Prevention of Recurrences in Rheumatic
Subjects. J.A.M.A., 126: 490, 1944.

16. Dodge, K. G., Baldwin, J. S., and Weber, M. W.: The
Prophylactic Use of Sulfanilamide in Children with Inactive
Rheumatic Fever. J. Ped., 24: 483, 1944.

17. Wolf, R. E., Rauh, L. W., and* Lyon, R. A.: Preven-
tion of Rheumatic Recurrences in Children by Use of Sulfa-
thiazole and Sulfadiazine. J. Pediatrics, 27: 516, 1945.

18. Pilot, I.: Sensitiveness of Meningococci to the Sulfona-
mides, JAM. A., 127:310, 1945.

19. Garvin, E. R.: Sulfadiazine as Prophylactic Agent

Against Meningitis. U. S. Nav. Med. Bull., 44: 700, 1945.

September, 1946

283

20. Waksman, S. A.: Microbial Antagonisms and Antibiotic
Substances. New York: The Commonwealth Fund, 1943,
p. 271.

21. Dubos, R. J.: Bactericidal Effect of an Extract of a Soil
Bacillus on Gram Positive Cocci. Proc. Soc. Exper. Biol, and
Med., 40:311, 1939; J. Exper. Med., 70: 1, 11, 1939.

22. Dubos, R. J., and Cattanev, C.: Studies on a Bacteri-
cidal Agent Extracted from a Soil Bacillus; Preparation and
Activity of a Protein-Free Fraction. J. Exper. Med., 70: 249,
1939.

23. Flirsh, H. L., and Dowling, H. F.: Observations on

Continuous Intramuscular Method of Administering Penicillin.
A. J. M. Sciences, 210: 435, 1945.

24. Loewe, L., Rosenblatt, P., Russell, M., and Alture-

Weber, E.: Superiority of Continuous Intravenous Drip for

Maintenance of Effectual Serum Levels of Penicillin: Compara-
tive Studies, with Particular Reference to Fractional and Con-
tinuous Intramuscular Administration. J. Lab. and Clin. Med.,
30: 730, 1945.

25. Romansky, M. J., and Rittman, G. E.: A Method of
Prolonging the Action of Penicillin. Science, 100:196, 1944.

26. Romansky, M. J., and Rittman, G. E.: Penicillin: Pro-
longed Action in Beeswax-Peanut Oil Mixture. Bull. U. S.
Army Med. Dept., No. 81, 43, 1944.

27. Romansky, M. J., and Rittman, G. E.: Penicillin Blood
Levels for Twenty-Four Hours Following a Single Intramuscu-
lar Injection of Calcium Penicillin in Beeswax and Peanut Oil.
New Eng. J. Med., 233: 577, 1945.

28. Kirby, W. M. M., Leifer, W., Martin, S. P., Rammel-
kamp, C. H., and Kinsman, J. M.: Intramuscular and Sub-
cutaneous Administration of Penicillin Beeswax-Peanut Oil.
J.A.M.A., 129: 940, 1945.

29. Leifer, W., Martin, S. P., and Kirby, W. M. M.: The
Treatment of Gonococcal Urethritis with Single Injections of

Penicillin-Beeswax-Peanut Oil Mixture. New Eng. J. Med.,
233: 583, 1945.

30. McDermott, W., Bunn, P. A., Benoit, M., DuBois, R.,
and Reynolds, M. E.: The Absorption, Excretion, and Destruc-
tion of Orally Administered Penicillin. J. Clin. Invest.,
25: 190, 1946.

31. Barach, A. L., Silberstein, F. H., Oppenheimer, E. T.,
Hunter, T., and Soroka, M.: Inhalation of Penicillin Aerosol
in Patients with Bronchial Asthma, Chronic Bronchitis, Bron-
chiectasis and Lung Abscess: Preliminary Report. Ann. Int.
Med., 22: 485, 1945.

32. Segal, M. S., and Ryder, C. M.: Penicillin Aerosoliza-
tion in the Treatment of Serious Respiratory Infections: A Pre-
liminary Report. New Eng. J. Med., 233:747, 1945.

33. Hamburger, M., Jr., Green, M. J., and Hamburger,
V. G.: Problems of "Dangerous Carrier” of Hemolytic Strep-
tococci: II. Spread of Infection by Individuals with Strongly
Positive Nose Cultures Who Expelled Large Numbers of Hem-
olytic Streptococci. J. Infect. Dis., 77: 96, 1945.

34. Hamburger, M., Jr., and Lemon, M. M.: The Problem
of the Dangerous Carrier of Hemolytic Streptococci. III. The
Chemotherapeutic Control of Nasal Carriers. J.A.M.A.,
130: 836, 1946.

35. Schatz, A., Bugie, E., and Waksman, S. A.: Streptomy-
cin, a Substance Exhibiting Antibiotic Activity Against Gram-
Positive and Gram-Negative Bacteria. Proc. Soc. Exper. Biol,
and Med., 55: 66, 1944.

36. Feldman, W. H., Hinshaw, H. C., and Mann, F. C.:
Streptomycin in Experimental Tuberculosis. Am. Rev. Tubercu-
losis, 52: 269, 1945.

37. Hegarty, C. P., Thiele, E., and Verwey, W. F.: The
In Vitro and In Vivo Activity of Streptomycin Against Hem-
ophilus Pertussis. J. of Bact., 50:651, 1945.

RED CROSS NURSES RECRUITED AS POLIO THREAT GREW

In late July close to three hundred nurses from all sections of the country were recruited
by the American Red Cross within a few days for poliomyelitis service in a dozen states.

Additional nurses are being recruited by Red Cross chapters and paid by the National
Foundation for Infantile Paralysis, as new and continued outbreaks of the disease occur. Nurs-
ing leaders of all Red Cross chapters have been alerted to draw from their disaster nurse re-
serves, when requested, for assignment to affected states. States requiring additional nursing
help include Minnesota, South Dakota, Kansas, Oklahoma, Illinois, Texas, Missouri, Louisiana,
Mississippi, Alabama, and Florida. Polio cases in 1946 have been listed by the U. S. Public
Health Service in every state except two, Nevada and Rhode Island.

As an aid to nurses, the first institute sponsored jointly by American Red Cross chapters
and the National Foundation for Infantile Paralysis as demonstration and instruction in polio-
myelitis nursing techniques, recently was completed in Nashville, Tennessee. Approximately
two hundred fifty nurses attended. Plans are under way for similar institutes to be held in
other localities.

Courses for Red Cross nurse’s aides, in care of convalescent polio patients, instituted sev-
eral years ago, are continuing currently in all sections where the disease has reached epidemic
proportions.

Under broadened policy for nurse recruitment in epidemics, the Red Cross is prepared to
call nurses for emergency service in communicable disease outbreaks even though epidemic
proportions have not been reached. This is part of the Red Cross general recruitment program
for nurses in all disasters. Through efforts of local nursing leaders in Red Cross chapters, the
list of disaster reserve nurses constantly is being strengthened to meet year ’round emergencies.
— American Red Cross News Release, Aug. 4, 1946.

284

The Journal Lancet

The Graduate Student and Research*

Owen H. Wangensteen, M.D.f
Minneapolis, Minnesota

This occasion, upon which we meet to honor the men
and women who have manifested an interest in
scholarship and scientific research, and whose labors have
attracted the notice of their teachers and fellow workers
in science, is an important annual university calendar
event, for you men and women represent the promise of
the future. Advances in knowledge are dependent upon
the anxiety of persons like you to contribute to the patri-
mony of knowledge.

The primary motive that impels undergraduates to
become graduate students in most instances, undoubtedly,
is a desire or thirst for more learning and instruction in
a field that appeals to the student. In brief, the student
desires to become a specialist of sorts. In this quest the
earnest student soon learns how true was the characteriza-
tion of science by Oliver Wendell Holmes, the medical
poet, when he said: "Science is the topography of ignor-
ance.” The zealous graduate student recognizes early his
obligation to contribute to the reservoir of knowledge
from which he has been ladling out to himself generous
portions of information.

Students who fail to get beyond the spoon-feeding
phase remain in the nursery stage of development and
never attain mature growth. The student with a good
appetite for knowledge soon learns that the occasional
feeding by his teacher does not appease his hunger. He
learns how to feed himself. Moreover, the earnest stu-
dent’s conflict with unsettled problems drives him on, and
soon he is consumed with a desire to try to add a few
tidbits to the stores upon which he has been drawing so
generously in his formative years. In the beginning, he
probably sallies forth in the spirit of adventure like a
boy starting out on a bright spring morning for an out-
ing in the country. It is only a diversionary amusement
for a day, and then back to the old routine. But the
attractions of research frequently prove far more fascin-
ating than the student had dreamed; he will stay another
day to enjoy the promising prospects of the outing.
Days and weeks go by and when the student returns
from his adventure, his outlook on life has changed.
What he undertook as momentary recreation has now
become an absorbing interest of his life.

If any of you recognize within yourselves some of
these symptoms, you have caught the contagion of a
highly infectious disease. It is an ailment, however, that
most of its victims enjoy, even though they may not talk
much about it, as many are prone to do of their physical
ailments. This new-found pleasure gives to life a zest
and flavor that only those who have tasted it can appre-

*The President’s address presented before the 50th annual
initiation of the Minnesota Chapter of Sigma Xi, June 8, 1945.
Reprinted from Bulletin of the Minnesota Medical Foundation ,
vol. 5, pages 91-99, June, 1945.

fChief of the Department of Surgery, University of Min-
nesota.

ciate. For them, research must be a constituent of the
daily diet, without which life seems dull and drab.

What Is Research?

Research probably connotes various things to people in
different walks of life. In the main, however, it can
truthfully be said, the American public does not need
to be convinced of the importance of research. On every
hand, we see what patient fact-finding has done to im-
prove our everyday existence. The pauper of today en-
joys luxuries denied kings of less than half a century
ago, largely because of contributions of science to the
conveniences of life, which most of us are quick to
regard as the necessities of life.

A pragmatist, somewhat skeptical of the value of re-
search, may tell you that it consists in proving the ob-
vious in a most thorough manner by laborious means.
Another may tell you, as the name implies, it means look-
ing again very carefully. The husband complains that
he cannot locate his dressing gown. The wife, schooled
in the importance of method, goes to the closet and with-
out apparent effort finds readily what had thrown hus-
band into confusion. Research is that simple, they will
tell you. All you need is method and time to do it.
Others may tell you that a researcher is a person who
does not know what he is looking for but is not happy
till he finds it.

I have the impression that there may be some truth
in all these suggestions. The most fundamental requisite
of a research project is an idea. A disciplined imagina-
tion is at the bottom of every great discovery. The per-
son professing to want to do some research must be look-
ing for something. He may not know exactly what he
is looking for, but he is conversant enough with the situa-
tion under scrutiny to recognize that the problem is un-
solved and demands an answer. A person with an idea,
possessing also a capacity for critical analysis, affords real
promise of a hopeful prospect in the solution of a prob-
lem. If, in addition, he is master of a method or tech-
nique by which the problem can be approached, the situ-
ation is even more promising. Not uncommonly, how-
ever, these two abilities are not associated. That is, per-
sons with ideas lack intimate knowledge of methods,
tools, or techniques by which to undertake the solution
of a problem. And frequently, too, persons who have an
intimate acquaintance or mastery of techniques are de-
void of ideas. Obviously, therefore, for the successful
prosecution of research, a combination of talents fre-
quently is necessary, in which a fusion of effort with
others gives an accelerated momentum to the project.
No one was ever great by imitation.

The touchstone of the scientific method is the univer-
sal validity of its results. It establishes a finality of proof
and agreement which puts aside all speculative rationali-
zation. Such is the superiority of the experimental meth-
od over logic. John Hunter, who introduced the scien-

September, 1946

285

tific method of collecting and classifying facts in surgery,
said to his pupil Edward Jenner of smallpox vaccination
fame: "Don’t think; try the experiment!”
Co-operative Research

The war has indicated in a convincing manner what
can be done through the agency of co-operative research.
A certain thing needs to be done. But how to do it?
The best minds and the best available talent having an
interest and acquaintance with the problem under scru-
tiny are brought together. Ideas and methods are pooled;
barriers are broken down; the impetus of many hands,
facilities and liberal support under wise guidance with
frequent discussions lend assurance that real progress will
be made. Employing this principle of operation, this coun-
try mobilized effectively for war on a gigantic nation-
wide scale that permeated into every activity of life with
almost incredible results. There probably comes a time
in many important researches progressing at a snail-like
pace, when this principle of co-operative effort will ad-
vance considerably the ultimate solution of the problem.

This circumstance suggests that in many problems
there are facets known only to certain persons; and that,
if an over-all picture could be put together by a fusion
of knowledge of the subject, or of knowledge of methods
by which an answer to the problem can be arrived at,
the final solution of the problem may be quickened by
years or decades. Undoubtedly, there are such isolated
facts buried in the scientific catacombs of our libraries,
which facts if known to the person who should be in
possession of that knowledge, would save endless labor
and supply the information necessary for the solution of
the problem. Scientific workers would do well to imple-
ment means to guard against failure in their researches
from this lack of perspective. At the same time, it must
be confessed, there are pressing problems not amenable
to solution by such synthesis — problems which must await
the penetrating clairvoyance of methods yet not available
or the discerning dreams of a Joseph or a Daniel to
resolve the mystery which blocks their solution. Study,
discussions, and integration of related talents and knowl-
edge help to expedite such synthesis of information, but
when essential facts are missing, the research can inch
forward only as that knowledge becomes available.

The Great Importance of a New Fact

A new fact can change the whole complexion of a
problem. How very true and how plodding a process the
discovery of a single new fact can be! How many papers
and books would never be published if the hurdle of con-
taining a single new fact had to be met! This effort, like
a lot of others, would wither under such a critical exam-
ination and never see the light of day. Little wonder that
a new fact is a priceless possession and that we immor-
talize the names of men who have added a single impor-
tant fact to knowledge. The pedantry of authority must
give way before the testimony of a new fact. Does it not
strike you as odd that our textbooks of today, though
perhaps more numerous, in the main, are not much
larger in a given well-established field than they were at
the beginning of the century? The deletion of barnacles,
the correction of mistruths and repeated errors, copied

out of other textbooks in the compilation, and the very
paucity of established new facts limit the size of our
textbooks of instruction.

Synthesis of Known Facts
It is very reassuring, however, that progress can be
made by the synthesis of well-known facts and through
minor improvements here and there, without the painful
and slow process of the birth of a new idea. Let me illus-
trate from my own field of surgery: Twenty to thirty
years ago, operations upon the thorax involving excision
of the thoracic esophagus for cancer, as well as opera-
tions upon the lung for excision of one or more of its
lobes for bronchiectasis, were being undertaken by sur-
geons interesting themselves in thoracic surgery. The
results were disastrous, and I know of at least one well-
known thoracic surgeon who gave up intrathoracic sur-
gery because of the risks involved. In the intervening
years, a wholly new situation has come about in this dif-
ficult field of surgery, without the discovery of a single
major new fact. The methods employed are really the
same as those used by the pioneers in this field, with this
difference: time has pointed out the essentials in carry-
ing such procedures forward to a satisfactory conclusion.
To be sure, there have occurred improvements in anes-
thesia, in operative technique and in the preparation of
the patient for, as well as after, operation. Yet, all of
the essential items involved in the successful performance
of these procedures were known when the pioneers in
the field were making the initial skirmishes with the
problem. In other words, experience has been a big fac-
tor in reducing the mortality in pulmonary lobectomy
from 50 to 1 or 2 per cent. And experience is only to
be acquired by a thorough study of the recorded experi-
ence of others aided by a critical analysis of the problem
gained through a personal acquaintance with it. I repeat,
it is very reassuring to know that important progress can
be made on a problem, by synthesis of well-known facts
and experience, even in the absence of new facts.

Basic and Applied Research
These considerations suggest the propriety of saying
something concerning the relationship of applied to basic
research. Let me illustrate from a major development
that has occurred in the medical field. In 1929, Fleming,
a bacteriologist at St. Mary’s Hospital in London, while
working with colonies of staphylococci, noted that con-
tamination of his colonies with a mould, later identified
by him as penicillium, exhibited a definite inhibiting
effect upon the growth of bacteria. Nothing more was
done with the matter until much later. When Florey
(1941), a pathologist at Oxford, and his associates, in
surveying substances exhibiting antibacterial action, found
that penicillium was one of the most powerful antibac-
terial substances extant against certain Gram-positive or-
ganisms, they began the co-ordinated program of pro-
duction to which many British and American laboratories
have devoted their entire facilities. Fleming, the discov-
erer of penicillin, little recognized the importance of his
discovery. It remained for Florey and his associates to
point out the real significance of that discovery. Drs.
Howard W. Florey and Alexander Fleming were both

286

The Journal Lancet

knighted by the King for their important contribution
to the control of bacterial infection.* How many more
years would Fleming’s observation have gone unheralded
had not Florey been casting about to test the potency of
known antibacterial agents? Had Fleming been a chem-
ist, it is to have been expected that a definite lag of years
should intervene between discovery and appreciation of
its importance. In this instance, however, both men were
physicians, one a bacteriologist, the other a pathologist.
Great credit is owing the person who first appreciates
and points out in a forceful manner the application to
which a discovery can be put. What I am trying to
point out is that really two persons participated in the
discovery. And so it is with many discoveries. It was
Whipple and his associates (1918) who demonstrated
the hematopoietic efficacy of a liver diet in dogs in the
management of anemia. It remained for Minot and
Murphy (1926) to establish that such treatment was
equally effective in the management of pernicious anemia
in man. The Nobel Prize Committee rightfully divided
the honors of this great discovery among the three. Had
it been possible to bring about the clinical syndrome of
pernicious anemia in the dog, Whipple and his associates
undoubtedly would have completed the entire experiment
themselves and hastened the practical application of a
life-saving remedy.

Medicine is commonly regarded as a field of applied
science. Yet basic discoveries can and are being made by
workers engaged primarily in applied research. The dis-
tinction between basic and applied research is occasionally
more arbitrary than real. An integrated co-operative
effort on a broad base should of necessity include inves-
tigators from pure science as well as applied fields.

The Support of Research

Industry recognizes the value of research, and most
forward-looking industries support research liberally.
Such a policy brings a rich reward directly back into the
treasuries of industry. Foundations, research institutes,
and universities also are vitally interested in research. In
the instance of this latter group of institutions, however,
there is little or no opportunity for research to be self-
supporting. They derive their support largely from phil-
anthropic persons interested in promoting the public
good. State universities in latter years are finding legis-
latures in a more receptive mood when appropriations are
asked for research. Daniel Webster, while seeking a fed-
eral appropriation for his native New Hampshire, was
asked what the state produced. "Men,” said Webster,
"and God has graven their image in the granite of her
hills.” With the growth of graduate schools, primarily
responsible for the sponsorship of research in universities,
it might be well to suggest the following addition to such
a query when asked of universities: Out of the labors of
our scientific workers engaged in research, a liberal, yes,
a munificent, return is made to society on the money
made available for purposes of research.

There is obviously a limit to which state universities
can support research without compromising the larger

*The Nobel prize in medicine for 1945 was awarded to
Fleming and Florey and the latter’s associate, Dr. E. Chain.

responsibility of the university of providing opportunities
for education on a broad base to its maturing men and
women. In Minnesota, which stands eighteenth in popu-
lation and twenty-third in wealth among our states, we
have a total student enrollment which ranks third among
American universities, exceeded only by Columbia and
California. The graduate school, though a more recent
development at Minnesota, has exhibited real growth and
represents an achievement of which we may well be
proud. The formal development of a graduate school
came as a result of the vision of George Vincent, our
third University of Minnesota president. Under Presi-
dents Burton, Coffman, Ford and Coffey, the graduate
school has grown. To Dr. Ford in particular, however,
large credit is owing for the great care with which he
nurtured and watched over its expansion during his
twenty-five years of stewardship as Dean of the Grad-
uate School.

A year ago President Coffey appointed an all-univer-
sity Advisory Committee composed of seventeen mem-
bers of the graduate faculty to study the matter of the
organization of research in the University. That com-
mittee, under the aegis of Dr. William S. Miller, its
chairman, and Dr. Lee I. Smith, the secretary, held a
number of meetings during the past year and devoted
considerable thought and study to the problems hedging
about the organization of research. As a member of that
committee, I wish to say that the deliberations of the
group were characterized by a serious and high-minded
interest in the future of research at this institution. Over
a period of many years, there has grown up here at
Minnesota an atmosphere and a spirit of friendly co-
operative helpfulness conducive to research. These vital-
izing influences, so essential for the stimulus and the
growth of research, permeate the entire institution. You
can feel it on every hand, in the attitude of the adminis-
tration as well as in one’s contacts with members of the
graduate faculty.

There are epochs in the development of every institu-
tion. The keen interest of the people of Minnesota in
education is apparent. Our university has attained its
present stature of growth on a broad base, largely because
the people of Minnesota have wanted superior educa-
tional advantages for their children, and have been sym-
pathetic with and ardent in their support of the dreams
and ambitions which our university leaders, presidents
and successive Boards of Regents alike, have cherished
for our university.

The time has come, however, when even greater im-
portance must be attached to the growth and expansion
of the graduate school. If Minnesota is to continue in
the vanguard of progress amongst educational institu-
tions of this country, an effort must be made to give
increased impetus to the functions of the graduate school.
Its activities have been carried on largely as a by-product
of university departmental teaching divisions.

Integration of Teaching and Research

In a sense, it is mandatory that students have some
contact in the classrooms with the most productive
scholars of the university. At the same time, that con-
tact, if not too heavy a teaching obligation, is equally

September, 1946

287

important for members of the graduate faculty interest-
ed in reseach. Our own late Dean Lyon, who was keen
for integration of teaching and research, said of his own
famed teacher in physiology, Jacques Loeb: "To my

mind, science lost rather than gained when Loeb left the
university for the research institute.” Many in the med-
ical field, I know, garner ideas for their research out of
the problems of their daily activity. To isolate them
from that source is to make them sterile; to load these
same men down with busy teaching schedules and too
much responsibility for the care of patients, is to de-
prive them of the time or the energy to do research.
Dean Lyon, I believe, was right in his insistence that a
proper admixture of teaching and research was healthful
and helpful to both.

Of some of us who lead dual lives in desiring to be
both teacher and investigator, our very good friends may
say — and mark you, criticism is the life of research, with-
out which the scientific approach to problems cannot sur-
vive— that one of these objectives is ambition enough for
any man, and singleness of purpose is necessary for the
success of any important enterprise. Benjamin Rush,
well-known physician of the American Revolution, said
of himself: "Medicine is my wife and science my mis-
tress.” To this self-avowal of dual interests, Oliver
Wendell Holmes is said to have remarked: "I do not
think that the breach of the seventh commandment can
be shown to have been of advantage to the legitimate
owner of his affections.” However much this invective
may strike home in the experience of any one of us,
I am inclined to believe that most of you will agree with
me when I say that research gives enlightenment and
meaning to our teaching, and teaching the controversial
problems of our special fields of activity affords problems
and ideas for our research. A career combining teaching
and investigation offers reciprocal advantages to both.

The Graduate School and Its Budget

In our university, the graduate school itself has a very
small budget, the faculty of the graduate school deriving
their emolument from the undergraduate departmental
teaching divisions of the university. As the teaching pro-
grams of these divisions expand, it is axiomatic that less
time is available for research. In the preamble of the
document prepared by the president’s Advisory Com-
mittee on proposed plans of organization for research,
Dr. Lee Smith and his associates said:

"In any scholarly activity, the prime factor is the scholar —
the thinker who possesses vision, patience, industry, and mas-
tery of his field of learning. However, the best of scholars is
in a futile position when he is deprived of time, for research is
not only a time-consuming activity in itself, but it must be pre-
ceded and accompanied by thinking. This thinking can seldom
be done upon a scheduled basis; it requires unhurried time, for
it is not the sort of thing that can be made to flow mechan-
ically like the numbers from a calculating machine. Considera-
tion of economy alone indicates that the able research man
should be spared from dissipating his time from day to day
upon many matters which can as well be entrusted to others.
... It has been said, quite aptly, that a university, to gain and
maintain a high intellectual position, must strive to retain the
able original scholars which it already has, and must be alert
always to attract to its faculty a stream of new scholars of estab-
lished attainments or of recognized promise. It is admitted,
moreover, that the prime requisite for the functioning of any
institution as a source of scholarly production is the presence

in it of a faculty of distinguished talent. These facts being
taken for granted, it follows that research and graduate educa-
tion as university activities are no less important than under-
graduate teaching, and that research and graduate education
should be represented in the administrative scheme of the uni-
versity by as high a position as is any other of the university
activities.”

Recruitment of Scientific Workers
Into Research

On this occasion, we meet to acknowledge your inter-
est in research and to bestow upon you the badge of
membership in the scientific fraternity of Sigma Xi for
your accomplishment. Many of you, I know, have earned
graduate degrees as well. However much you prize that
recognition for sentimental or more apparent reasons,
let me remind you that it is your participation in a con-
tribution to knowledge and demonstrated interest in re-
search that brings us together tonight, and not the win-
ning of a graduate degree. In honoring you, we are re-
minding ourselves that the research workers and teachers
of tomorrow must be sought in and recruited from
groups such as this. A desire to learn is equally as im-
portant as ability in the learning process. Similarly in
research, enthusiasm for the work must go hand in hand
with native talent.

A university would do well to see to it that its faculty
use all legitimate means to persuade those of you who
have manifested real ability to do research to remain in
the game. We can point out to you the large rewards,
of which perhaps the greatest is the personal satisfaction
in the knowledge of a task well done. "Contented in-
dustry,” the late Dr. William J. Mayo said frequently,
"is the mainspring of human happiness.” And if that
labor has to do with advancement of knowledge and the
betterment of man and his environment, what employ-
ment could give greater happiness?

We must be realistic, however, and offer you an op-
portunity with promise and a financial reward adequate
for your needs. It is this latter matter that is often the
stumbling block. In an integrated teaching and research
program with all positions on the budget filled, the
acquisition of a new faculty member is not a simple
matter, as those of us who have had experience with
budgets well know. Yet, here is an item of the greatest
importance for the university. If this university is to
maintain the eminent position it has acquired amongst
educational institutions, the cultivation of a faculty de-
voted to the advancement of learning must take on ac-
celerated momentum. The University of Minnesota is
now in its ninety-fourth year of existence, but it is really
only within the thirty-year period of time, marking the
beginning and rise of the graduate school, that the Uni-
versity of Minnesota has come to the fore as an impor-
tant educational center. The growth of the institution
on a broad base is largely over. Renewed emphasis must
now be lent to maintaining and extending its influence
in the advancement and enlargement of knowledge —
otherwise decadence is in store for us. The rise and fall
of faculties and empires is a matter of common knowl-
edge. The leadership that has made the University of
Minnesota great, it must continue to have. As we con-
template the future of our university, it is apparent that

288

The Journal Lancet

a more liberal support of productive scholarly activity
and research is essential for the continued growth and
improvement of those qualities that have brought distinc-
tion to our university.

Monies Available for Research

A study of the sources of the money which have been
available to the university sheds interesting light on the
problem of the support of research. A study of the sum-
mary of gifts to the university from 1851 to 1942, from
other than legislative sources, compiled by the Comp-
troller’s Office, indicates that during these ninety-one
years a total of $14,828,091.75 was received. Approxi-
mately 10 per cent of this amount came from alumni of
the university. During the six-year interval (three bi-
ennial periods) from 1941 to 1947, the legislature appro-
priated a total of $31,052,543. In other words, over a
period of six years, the legislature put at our disposal
somewhat more than twice the amount of money made
available to the university from all other sources over a
ninety-one-year period. Of the monies appropriated by
the legislature, slightly more than 4 per cent was set
aside for specific research purposes. This latter figure,
in a sense, is fictional, however, for all of us on the grad-
uate faculty derive our salaries from our respective de-
partmental teaching budgets.

During the school year 1942-1943, the university re-
ceived gifts in the amount of $301,013.16. Of this
amount, $235,383.16 came from a number of miscella-
neous sources; the remaining $65,630 was constituted by
federal grants administered through the Office of Scien-
tific Research and Development. In addition, during the
school year 1942-1943, $18,977.68 accrued for purposes
of research as income from endowments. During the
same period, $103,562.37 accrued as income from endow-
ments for research for expenditures by the Mayo Foun-
dation at Rochester.

This superficial and somewhat cursory survey of the
sources of university support suggests definitely the need
of making a studied effort to enlarge considerably our
sources of revenue from gifts. President Coffey said
recently on the occasion of the testimonial dinner in his
honor: "The University of Minnesota needs more influ-
ential friends.” The booklet entitled "An Interpretation
of an Economic Analysis of the State of Minnesota”
(1945) representing a summary of the studies of the
Minnesota Resources Commission, though giving em-
phasis to the importance of research in the solution of
the problem of the declining per capita wealth in Min-
nesota, affords little hope that we may expect even larger
legislative appropriations for educational purposes.

The plan of organization of research proposed and
endorsed by the majority of the members of President
Coffey’s Advisory Committee, envisages the prospect of
having one of the senior administrative officers of the
graduate school devote time and thought to the problem
of securing a more liberal support of research through
gifts. The future of research at the University of Min-
nesota is directly dependent upon our ability to enlarge

considerably the support of research from private sources.
If the federal government undertakes to support re-
search in other fields as liberally as it has in agriculture,
a partial solution of our problem is in sight. Until that
comes about, however, President Coffey’s suggestion of
enlisting the sympathetic interest of our own influential
citizens in the cause of research appears to be the only
solution.

The Relationship of Research to the
Social Order

Training in research leads to an appreciation of the
value of evidence. The scientific method eliminates the
element of personal bias in controversial matters, and
asks only: What is the evidence? Science and research
have opened up for us a vast new world. They have not
alone revolutionized our conception of the universe, but
they have altered our entire mode of existence. Our
capacity to enjoy and appreciate the contributions of
research to life is limited largely by our ability to get on
with one another. When a cow is well fed, she lies down
content, and chews her cud. But the undisciplined pas-
sions of man are inconflict with his ability to secure for
himself peace of mind, which is the ultimate happiness.
What creatures other than man destroy their own kind
in a wanton manner? What progress have we made in
the observance of the moral law since the Sermon on the
Mount? Why, when books continuously are being writ-
ten and expounded on morality does their teaching ap-
pear to exercise so little influence upon the behavior and
conduct of man for the better? When will facts, an
appreciation of the value of evidence, and elimination
of the element of personal bias permit the scientific
method to operate effectively in our relations with our
fellow man? Perhaps Shakespeare supplied the answer
when he had Portia in the Merchant of Venice, say:

"If to do were as easy as to know what were good to do,
chapels had been churches, and poor men’s cottages princes’
palaces. It is a good divine that follows his own instructions.
I can easier teach twenty what were good to be done than be
one of the twenty to follow mine own teaching.”

Conclusion

The work of man in this world is the establishment of
order which is also heaven’s first law. It is to be hoped
that man may learn the value of the scientific method
in helping him get on with his fellow man, just as he
accepts gladly the gifts of scientific research to the en-
richment of his daily life. Research brings light where
there was darkness, and much as the world needs light
it stands even in greater need of an enlightened under-
standing. Few of us who profess to follow teaching and
research will be bringers of the light, but we can all be
ardent seekers after it, and strive mightily for an en-
lightened understanding. The graduate student who
centers his career about research, and who is driven by
an anxiety to contribute to the welfare of his fellow man,
will find in the accomplishment satisfaction and personal
happiness. I hope that none of you will abandon this
prospect which research holds out to all who follow her
with diligence and devotion.

September, 1946

289

Anopheline Mosquitoes in Montana

Donald J. Pletsch, Ph.D.*

Bozeman, Montana

The recent return to Montana of thousands of ex-
service personnel, some of whom still carry malaria
parasites, gives new importance to the problem of Mon-
tana’s anopheline mosquitoes. Twenty-six male students
at Montana State University, Missoula, apparently har-
bored malaria parasites in June, 1946 (according to Dr.
C. R. Svore, Director, University Health Service) . At
the same time twenty-two ex-servicemen at Montana
State College, Bozeman, had blood smears positive for
malaria.

pits”, swamps, pools, and slow-moving streams. Captured
adult anophelines were all identified as belonging to
species already known from the state, Anopheles puncti-
pennis and A. macuhpennis. In the larval and pupal
stages these two species cannot be readily distinguished
from one another, but attempts were made to rear the
immature forms to the adult stage. Results of the sur-
vey are summarized in Table 1, below.

Several interesting conclusions may be drawn from the
survey results. First, anophelines were more generally

Table 1

Anopheline Mosquitoes Found in Western Montana: April 19 — May 31, 1946

COUNTY

LARVAL

Number

Examined

HABITATS

Number

Positive

ADULT

Number

Examined

HABITATS

Number

Positive

ADULTS COLLECTED
Anopheles Anopheles

punctipennis maculipennis

Deer Lodge ...

Flathead

Gallatin

—

Granite

Jefferson

Lake

Lincoln

Mineral

Missoula ...

Powell

Ravalli ___

1 1

Sanders _

Total

Per cent positive samples

23.6%

21.8%

The presence of anopheline mosquitoes in Montana
has been recognized for many years. Mail (1934) listed
two species, Anopheles punctipennis and A. maculipennis,
both potential transmitters of malaria parasites. He con-
sidered Anopheles punctipennis unimportant because of
its rarity, as there was only a single record from Mon-
tana, at Lolo in the Bitterroot Valley. Regarding Anoph-
eles maculipennis, known from six records, he stated,
"Although this mosquito is the most important malaria
carrier in California, it is of no importance as such in
Montana. It is not sufficiently numerous to constitute
a pest.”

A survey was conducted for anopheline mosquitoes in
12 western Montana counties from May 20 to 31, 1946.
Earlier random collections had been made on April 19
and 29 in Mineral County. Adult anophelines were
sought in barns, cowsheds, outbuildings, under cabins, in
boxes and barrels, culverts, under bridges, and in similar
locations offering protection from wind and direct sun-
light. Dips for larvae were made in roadside "borrow-

* Associate Entomologist, Montana Agricultural Experiment
Station, Bozeman.

present in the area than previously supposed, and in
some instances were breeding in close proximity to towns
or cities. Second, the considerable numbers of larvae
found in some breeding places indicated favorable condi-
tions for development. This impression was confirmed
by finding adult anophelines in some instances (61 adults
under one bridge near Hot Springs, Sanders county) .
Third, the finding of male mosquitoes in numbers as
early as May 28 was evidence of a 1946 generation by
that date, as only the female Anopheles overwinter in
this latitude.

In addition to the twelve counties included in the 1946
survey, records of Anopheles are on hand for Lewis and
Clark, Valley, Phillips, and Blaine counties. It is likely
that intensive collecting would reveal small numbers of
anophelines in any part of the state.

The probability of indigenous malaria in Montana
remains very remote, but the possibility of such an occur-
rence cannot be discounted while potential transmitters
and persons harboring parasites are both present. Med-
ical practitioners in Montana should be aware of the pos-
sibilities of malaria with its variety of symptoms.

290

The Journal Lancet

Transactions of the North Dakota State Medical

Association House of Delegates

59th Annual Session
Bismarck, North Dakota, May 26, 1946

OFFICERS, 1945-1946

President .... JAMES F. HANNA, Fargo

President-Elect A. E. SPEAR, Dickinson

First Vice-President PHILIP G. ARZT, Jamestown

Second Vice-President W. A. LIEBELER, Grand Forks

Speaker of the House JOHN H. MOORE, Grand Forks

Secretary L. W. LARSON, Bismarck

Treasurer W. W. WOOD, Jamestown

Delegate to A.M.A. — 1946 A. P. NACHTWEY, Dickinson

Alternate Delegate to A.M.A. — 1946

W. A. WRIGHT, Williston

COUNCILLORS

Terms Expiring 1946

Second District J. C. FAWCETT, Devils Lake

Seventh District JOSEPH SORKNESS, Jamestown

Eighth District F. W. FERGUSSON, Kulm

Tenth District W. H. GILSDORF, Valley City

Terms Expiring 1947

First District PAUL BURTON, Fargo

Third District C. J. GLASPEL, Grafton, Secretary

Sixth District N. O. RAMSTAD, Bismarck, President

Terms Expiring 1948

Fourth District A. D. McCANNELL, Minot

Fifth District C. J. MEREDITH, Valley City

Ninth District A. E. WESTERVELT, Bowdon

HOUSE OF DELEGATES

CASS COUNTY

V. G. BORLAND

O. A. SEDLAK

A. L. KLEIN, Alternate

S. C. BACHELLER, Alternate

B. A. MAZUR, Alternate

DEVILS LAKE

G. W. TOOMEY Devils Lake

W. R. FOX, Alternate Rugby

GRAND FORKS

P. H. WOUTAT Grand Forks

G. L. COUNTRYMAN _____ Grafton

L. H. LANDRY, Alternate _ __ Walhalla

KOTANA

W. A. WRIGHT Williston

I. S. AbPLANALP, Alternate ..Williston

NORTHWEST DISTRICT

A. R. SORENSON Minot

D. J. HALLIDAY Kenmare

M. T. LAMPERT, Alternate Minot

RICHLAND

A. H. REJSWIG Wahpeton

C. V. BATEMAN, Alternate Wahpeton

SHEYENNE VALLEY

PAUL T. COOK Valley City

A. C. MacDONALD, Alternate Valley City

SIXTH DISTRICT

C. C. SMITH Mandan

R. H. WALDSCHMIDT Bismarck

M. S. JACOBSON, Alternate .... Elgin

SOUTHERN

F. E. WOLFE Oakes

VICTOR FERGUSSON, Alternate __ Edgeley

SOUTHWESTERN DISTRICT

A. P. NACHTWEY Dickinson

R. W. RODGERS, Alternate Dickinson

— Fargo

Fargo

Enderlin
Fargo

STUTSMAN COUNTY

W. W. WOOD Jamestown

P. G. ARZT, Alternate . Jamestown

TRI-COUNTY

M. J. MOORE New Rockford

F. W. FORD, Alternate New Rockford

TRAILL-STEELE

O. A. KNUTSON Buxton

R. C. LITTLE, Alternate Mayville

STANDING COMMITTEES

COMMITTEE ON MEDICAL EDUCATION

H. E. FRENCH, Chairman Grand Forks

J. H. FJELDE Fargo

C. R. TOMPKINS Grafton

R. E. LEIGH Grand Forks

COMMITTEE ON NECROLOGY AND MEDICAL HISTORY

F. L. WICKS, Valley City ) r ru ■

G. M. WILLIAMSON, Grand Forks ) '~°-'“ha,rmen

L. H. KERMOTT Minot

ROLFE TAINTER Fargo

O. C. MAERCKLEIN Mott

M. W. ROAN Bismarck

JESSE W. BOWEN Dickinson

IRA S. AbPLANALP Williston

COMMITTEE ON PUBLIC POLICY AND LEGISLATION

A. D. McCANNEL, Chairman Minot

A. P. NACHTWEY Dickinson

PAUL BURTON Fargo

G. M. WILLIAMSON Grand Forks

G. F. DREW Devils Lake

FRANK I. DARROW Fargo

F. L. WICKS Valley City

L. W. LARSON, ex-officio Bismarck

J. F. HANNA, ex-officio Fargo

COMMITTEE ON PUBLIC HEALTH

G. F. CAMPANA, Chairman Bismarck

A. C. MacDONALD Valley City

H. T. SKOVHOLT Williston

P. L. OWENS Bismarck

H. B. HUNTLEY Kindred

N. W. FAWCETT Devils Lake

L. H. LANDRY Walhalla

E. M. WATSON Fargo

R. G. WHITE Minot

A. S. CHERNAUSEK Dickinson

T. Q. BENSON Grand Forks

L. F. NELSON Bottineau

E. J. BEITHON Hankinson

R. C. LITTLE Mayville

MARY SOULES New England

W. A. GERRISH Jamestown

V. R. FERGUSSON Edgeley

COMMITTEE ON TUBERCULOSIS

J. O. ARNSON, Chairman

J. P. CRAVEN

G S. SEIFFERT

W. L. WALLBANK

VICTOR FERGUSSON

C. V. BATEMAN

J. C. FAWCETT

F. O. WOODWARD

V. J. LaROSE

F. E. WEED

A. F. HAMMARGREN

M. M. HEFFRON

H. E. GULOIEN

E. H. RICHTER

Bismarck

Williston

Minot

San Haven

Edgeley

Wahpeton

Devils Lake

Jamestown

Bismarck

Park River

Harvey

Bismarck

Dickinson

Hunter

September, 1946

291

COMMITTEE ON OFFICIAL PUBLICATION

L. W. LARSON, Chairman Bismarck

J. O. ARNSON Bismarck

H. D. BENWELL Grand Forks

W. H. LONG Fargo

G. W. TOOMEY Devils Lake

COMMITTEE ON CANCER

L. W. LARSON, Chairman . Bismarck

PAUL BRESLICH Minot

G. W. HUNTER Fargo

J. H. MOORE Grand Forks

COMMITTEE ON FRACTURES

R. H. WALDSCHMIDT, Chairman _. Bismarck

R. D. CAMPBELL Grand Forks

J. C. FAWCETT Devils Lake

J. W. BOWEN Dickinson

C. J. MEREDITH Valley City

J. P. CRAVEN Williston

E. J. LARSON Jamestown

H. J. FORTIN Fargo

A. F. HAMMARGREN Harvey

V. G. BORLAND Fargo

COMMITTEE ON MEDICAL ECONOMICS

W. A. WRIGHT, Chairman Williston

P. H. WOUTAT Grand Forks

F. E. WOLFE Oakes

W. H. LONG Fargo

A. D. McCANNEL Minot

R. H. WALDSCHMIDT Bismarck

R. W. RODGERS Dickinson

M. J. MOORE New Rockford

COMMITTEE ON MATERNAL AND CHILD WELFARE

J. H. MOORE, Chairman ... ....

.... Grand Forks

T. L. DePUY

P. W. FREISE

J. D. GRAHAM

J. F. HANNA

Jamestown

Bismarck

Devils Lake

Fargo

E. M. RANSOM .. .

. Minot

M. D. WESTLEY

Cooperstown

LAWRENCE PRAY

Fargo

COMMITTEE ON CRIPPLED CHILDREN

A. R. SORENSON, Chairman Minot

HARRY J. FORTIN Fargo

J. C. SWANSON Fargo

R. H. WALDSCHMIDT Bismarck

W. W. WOOD Jamestown

COMMITTEE ON

O. W. JOHNSON, Chairman

PNEUMONIA

Rugby

L. H. FREDRICKS

Bismarck

J. E. HETHERINGTON

Grand Forks

W. E. G. LANCASTER

W. H. GILSDORF

a. w. Macdonald

GUNDER CHRISTIANSON

Fargo

.... Valley City

Valley City

Sharon

SPECIAL COMMITTEES

COMMITTEE ON INDUSTRIAL HEALTH

C. J. GLASPEL, Chairman Grafton

W. H. BODENSTAB Bismarck

W. A. GERRISH Jamestown

COMMITTEE ON WAR PARTICIPATION

L. W. LARSON, Chairman Bismarck

N. O. RAMSTAD Bismarck

C. J. GLASPEL Grafton

F. W. FERGUSSON Kulm

A. R. SORENSON ...... Minot

FRANK I. DARROW Fargo

P. G. ARZT Jamestown

A. E. SPEAR Dickinson

W. A. WRIGHT Williston

C. J. MEREDITH Valley City

COMMITTEE ON NURSING EDUCATION

G. W. TOOMEY, Chairman Devils Lake

O. A. SEDLAK __ Fargo

R. E. LEIGH Grand Forks

WOODROW NELSON _ _ Minot

N. O. RAMSTAD Bismarck

REFERENCE COMMITTEES— House of Delegates

To consider the Reports of the President, Secretary and
Special Committees:

A. P. NACHTWEY, Chairman Dickinson

O. A. SEDLAK Fargo

PAUL T. COOK Valley City

To consider the Reports of the Council, Councillors,

Delegate to the A.M.A., and Member of the
Medical Center Advisory Council:

D. J. HALLIDAY, Chairman Kenmare

G. L. COUNTRYMAN Grafton

P. H. WOUTAT Grand Forks

To consider the Reports of the Standing Committees,

except the Report of the Committee on Medical Economics:

C. C. SMITH, Chairman Mandan

M. J. MOORE New Rockford

A. H. REISWIG Wahpeton

To consider the Report of the Committee on
Medical Economics:

V. G. BORLAND, Chairman — Fargo

A. R. SORENSON Minot

R. H. WALDSCHMIDT Bismarck

F. E. WOLFE Oakes

W. W. WOOD Jamestown

Committee on Resolutions:

W. A. WRIGHT, Chairman Williston

O. A. KNUTSON Buxton

G. W. TOOMEY Devils Lake

Committee on Credentials:

W. W. WOOD, Chairman Jamestown

A. H. WEISWIG Wahpeton

R. H. WALDSCHMIDT Bismarck

Proceedings of the House of Delegates of the
NORTH DAKOTA STATE MEDICAL
ASSOCIATION

First Session, Sunday, May 26, 1946

The House of Delegates convened in the Rose Room of the
Patterson Hotel, Bismarck, North Dakota. It was called to
order at 2:00 P.M. by the speaker, Dr. John H. Moore. Dr.
W. W. Wood, Chairman of the Committee on Credentials,
announced that thirteen elected delegates had presented their
credentials and were qualified. The secretary called the roll.
Fifteen delegates responded and the speaker declared a quorum
present. Delegates present were: Drs. V. G. Borland, Fargo;
P. H. Woutat, Grand Forks; W. A. Wright, Williston; A. R
Sorenson, Minot; D. J. Halliday, Kenmare; A. H. Reiswig,
Wahpeton; Paul T. Cook, Valley City; C. C. Smith, Mandan;
R. H. Waldschmidt, Bismarck; A. P. Nachtwey, Dickinson;
W. W. Wood, Jamestown; M. J. Moore, New Rockford; O. A.
Knutson, Buxton; O. A. Sedlak, Fargo; G. W. Toomey, Devils
Lake.

Introduction of President

The speaker introduced the President, Dr. James F. Hanna,
who welcomed the delegates back to a peace-time convention
and delivered the following address: "In Valley City, a year
ago, we held the first streamlined meeting. At that meeting the
House of Delegates discussed the pre-payment medical plan.
At that time I could not see the wisdom of it, but as time has
gone on, I see it is a wise plan.

"As I have gone on in the office of President, there have
been a few things that have struck me that would be beneficial
to the Association if they could be adopted. Until I took over
the office of President, I had been devoting my life to the prac-
tice of medicine. It became apparent after meeting with the
different committees that a man elected to a state office should
take a more active interest in the affairs of the Association than
any of us have done in the past. A presidency used to amount
to just going to a convention, having some fun, and then
waiting until next year. But now, it means more than that.
The President must keep abreast of other things than just the
sociability. I think it would be a good idea and I would like
to recommend that when a President takes over, he should
take on a more active duty. He should address the House of
Delegates. I also think the President-Elect should deliver the
address to the Convention. By so doing, he will feel more a
part of the Association.

292

The Journal Lancet

I am happy to report a year ago it was decided that we try
to procure an Executive Secretary, and we have procured him.
I would like to leave the thought with him, and with you as
well, that the medical profession needs alliances. I have spoken
to some members of the dental association and the lawyers.
Their turn is around the corner. It would not be out of line
if we could step out of the professional group, and I think it
would be a good thing for the medical profession to have liaison
to meet with similar groups from other professions. I think
that is one thing our new Executive Secretary could look into
and I would like to see him do so.”

The speaker then introduced several distinguished officials
and visitors, including Dr. A. E. Spear, Dickinson, President-
Elect; Dr. W. A. Liebeler, Grand Forks, Second Vice-Presi-
dent; Dr. George Williamson, Grand Forks, Secretary, Board
of Medical Examiners; Dr. N. O. Ramstad, Bismarck, Presi-
dent of the Council; Dr. Alfred W. Adson, Member of the
Council on Medical Service and Public Relations, American
Medical Association, Rochester, Minnesota; and Dr. L. W.
Larson, Secretary of the North Dakota State Medical Associa-
tion. Dr. Larson announced the procurement of a full-time
executive secretary and introduced Mr. E. F. Engebretson, who
had been selected for this position.

Minutes of 1945 Meeting Approved
On motion made by Dr. Nachtwey, seconded by Dr. Wald-
schmidt and carried, the reading of the minutes of the 1945
session as published and circulated in the August 1945 issue
of the Journal Lancet were dispensed with and the minutes
adopted.

REPORT OF THE SECRETARY

Dr. L. W. Larson, secretary, presented the following report
as presented in the handbook which was referred to the refer-
ence committee on reports of the secretary and special com-
mittees.

The total membership for 1945 was 379. Of this number
313 paid their annual dues, 9 were honorary members, and the
dues of 57 members were cancelled because of military service.
Six members died during the past year. Eight of those who
paid dues in 1944 failed to pay their 1945 dues. Four new
members were admitted to the Association during the year.
Table No. 1 shows the annual membership for the ppst seven
years. Although the total membership has remained almost
constant during this time, the figures show that we struck an
all-time low in 1945. This is due to deaths, removal from the
State, and delinquencies. The effect that the marked increase
in the dues for 1946-47 will have on our total membership is
difficult to predict.

Table No. 1

Comparison of Annual Membership

1939

1940

1941

1942

1943

1944

1945

Paid Memberships

394

387

374

366

331

318

313

Honorary Membership
Dues Cancelled,

military service

—

Total

397

398

400

408

403

387

379

Table No. 2 shows

that

the annual

dues

for

1946-47

are

being paid quite promptly. To date 305 members have paid
their dues, of which 12 are new members. Many of our mem-
bers who have been discharged from military service within the
past six to eight months, have returned to practice in the State,
although several are still on terminal leave, or are taking post-
graduate courses. Reports from the Component District So-
cieties indicate that several elderly, semi-retired, or retired mem-
bers, who formerly paid their Association dues, are dropping
out of the Association. The reason given is usually that the
dues are too high to justify the continuance of membership.
The figures indicate that unless a substantial number of new
physicians locate in the State, the membership of the Associa-
tion will not exceed 315 who pay dues.

Table No. 2

1941

1942

1943

1944

1945

1946

Paid-up Members

339

352

316

304

294

305

Honorary Members
Dues Cancelled,

military service

—

Total

351

393

384

373

360

Field Work- It has been impossible for your Secretary to
visit more than a few of the District Societies during the past
year. Fortunately, President Hanna has been able, and willing,
to attend District Meetings, so the Association has been repre-
sented at most of the District Societies at one time or another.
Interest in the District Societies is relatively active, although
the reports from the smaller societies indicate the need for more
frequent meetings and development of better scientific programs.

Your Secretary has tried to maintain contacts with the A.M.A.
and the North Central Medical Conference. Unfortunately, he
was unable to attend the Annual Conference of State Secre-
taries, held at the A.M.A. Headquarters during February, be-
cause of inclement weather. He did attend the First Annual
Conference on Rural Medical Service on March 30th, which was
sponsored by the Committee on Rural Medical Care of the
A.M.A. Representatives of the American Farm Bureau Federa-
tion, Grange, Farmers Union and the Farm Foundation were
present at this Conference, and your Secretary discussed one of
the papers.

Committees. As usual some of the Committees have been
very active during the past year. The Committee on Medical
Economics has continued its study of the problem of prepaid
medical insurance, and has also negotiated with the Veterans
Administration relative to a working arrangement between the
Veterans Administration and the Association for the provision
of medical care for the veteran. The Committee on Tubercu-
losis has actively cooperated with the State Health Department
in the development and promotion of the mass chest X-ray pro-
gram which is now in operation in the State.

Medical Economics. President Truman’s Health Program,
and the Wagner-Murray-Dingell Bill, are being discussed thor-
oughly in the Senate Committee hearings on the bill. A request
was submitted to Senator Murray, Chairman of the Committee
on Education and Labor, for an opportunity to appear before
the Committee. Permission was denied, although Senator Mur-
ray did request us to submit a brief for the Record. Reports
from the Washington headquarters of the Council on Medical
Service and Public Relations indicate that the medical viewpoint
has been well presented by the few who have been permitted to
testify before the Committee. There is some indication that
the proponents of the Wagner-Murray Bill are being given
more opportunity to present their case than the opponents of
the bill. The Council on Medical Service and Public Relations
of the A.M.A. is beginning to function in a satisfactory man-
ner. Our members will have an opportunity to hear one of
its members, Dr. A. W. Adson, during this meeting.

North Central Medical Conference. This organization, which
represents the medical profession in Minnesota, Wisconsin,
Iowa, Nebraska, North and South Dakota, continues to func-
tion as a potent force in the field of medical economics through-
out the country. The problems in the area are quite similar,
and there is every indication that the cooperative spirit which has
developed among the representatives of the states in the Con-
ference area, will be of value to the physicians they represent.

Full-time Secretary. I trust that a full-time Secretary will
be employed before our 1946 Annual Meeting. There is much
he can do to improve our public relations, and also to stimulate
the growth and development of our Component District So-
cieties. The hearty response of our members to the material
increase in dues this year indicates that our members favor the
employment of a full-time Secretary, and are willing to pay
for the additional cost.

I wish to thank the Officers of the State Association and the
Component District Medical Societies, and the membership, for
the cooperation they have given to me and the courtesies ex-
tended during the past year. President Hanna has been a
worthy successor to Dr. Wicks. He has given freely of his
time attending the meetings of the Governor’s Health Planning
Committee, District Societies, Northwest Regional Conference,
and the National Conference on Medical Service. It has been
a pleasure for me to work with him. I wish also to commend
Dr. W. A. Wright, Chairman of the Committee on Medical
Economics, for his willingness to attend local and national
meetings during the past year.

Recommendations

1. That the Association continue its financial support of the
North Central Medical Conference.

September, 1946

293

2. That the President-Elect and Vice Presidents be utilized
more in the future than they have in the past. They should
continue as members, or Chairmen, of important committees,
or they should be assigned to special duties which will acquaint
them with the mechanics of the Association and the problems
confronting its membership.

REPORT OF TREASURER

Dr. W. W. Wood, treasurer, presented his report as pub-
lished in the handbook.

Balance in checking account, April 15,

1945, less check No. 509, uncashed $ 2,712.70

Receipts of dues during the year 10,865.00

Bond interest received 112.50

$13,690.20

Disbursements:

Checks No. 511 to 520, inch ....... $ 2,273.82

Bank expense 16.50

2,290.32

Balance in bank, May 1, 1946, check account $11,399.88

Bonds in safety deposit 4,500.00

Total assets $15,899.88

REPORT OF CHAIRMAN OF THE COUNCIL
1945-1946

Dr. N. O. Ramstad, chairman, presented the following re-
port, which was referred to the reference committee on reports
of the council, councillors, and delegate to the American Med-
ical Association.

The Council of the North Dakota State Medical Association
met in Valley City, North Dakota, May 20 and 21, 1945.
Nine members were present. Also present were President F. L.
Wicks and Secretary L. W. Larson of the State Medical Asso-
ciation, who are ex-officio members. Others attending were
President-elect J. F. Hanna, Dr. G. M. Williamson, and First
Vice President A. E. Spear.

Secretary L. W. Larson reported a paid membership of 304
and 10 honorary members. The dues of 59 members in the
military services were omitted. Doctor Larson recommended
that Doctor Wright be fully paid for his expenses connected
with the Committee on Medical Economics, and that President
Wicks be allowed a sufficient sum to meet his travel expenses.

The treasurer, Dr. W. W. Wood, read his report to the
House of Delegates. The Association has invested $4,500 in
United State Bonds and had a balance of $2,772.70 in the
bank. The value of the physical assets of the Association, after
depreciation, was $91.15. The Secretary reported that his ex-
penses for the fiscal year were as follows:

Postage and office supplies ...... $ 296.28

Telephone and telegrams ... 27.97

Travel Expenses 90.78

Salary ...... 1,200.00

Total $1,615.03

The auditing committee of the Council reported that the
accounts of the Secretary and Treasurer had been examined
and found to be correct. This report was approved by the
Council. The Council also approved the payment of the pre-
miums on the bonds of the Treasurer for $20,000 and the
Secretary for $5,000.

The contract with the Journal Lancet was renewed for
two years.

The following budget for the coming year was prepared and

approved by the Council:

North Central Conference $ 50.00

Committee on medical economics 100.00

Stenographer for annual meeting 150.00

Emergency fund for chairman of the council 50.00

Emergency fund for the council 200.00

1946 annual meeting 200.00

A M. A. delegate ... 125.00

Journal Lancet 650.00

Secretary’s salary 1,200.00

Postage and office supplies 175.00

Telephone and telegrams 50.00

Travel expenses for the secretary 150.00

Travel expenses for the president 100.00

The editorial committee of official publications was reappoint-
ed: L. W. Larson, chairman, J. O. Arnson, H. D. Benwell,
W. H. Long, and G. W. Toomey.

The officers elected by the Council for the coming year were
N. O. Ramstad, chairman, and C. J. Glaspel, secretary.

After conference with President J. F. Hanna and Secretary
L. W. Larson, it was decided that a mid-year meeting of the
Council was not necessary.

In December, 1945, Dr. A. D. McCannel reported that the
local medical society in Minot could not entertain the State
Medical Association in 1946 because of the lack of hotel ac-
commodations. After consulting with President J. F. Hanna,
a vote of the members of the Council was taken by mail to
choose the location of the 1946 meeting. Bismarck was selected
by a majority vote.

No controversial matters were presented for action by the
Council during the year.

Respectfully submitted,

N. O. Ramstad, M.D., Chairman of Council

REPORTS OF THE COUNCILLORS

The following reports of the Councillors as published in the
handbook were referred to the reference committee on reports
of the council, councillors, and delegate to the American Med-
ical Association.

First District

The following is a resume of the proceedings of the Cass
County Medical Society for the year 1945, as submitted by
Dr. Charles Heilman, Secretary:

"During 1945, the Cass County Medical Society held nine
regular meetings. As has been our custom in previous years,
a dinner meeting on the last Monday of each month is held
at the Gardner Hotel, following which a business meeting and
scientific program is enjoyed by members and their guests.
A large number of guests regularly attend these meetings from
the surrounding counties in both Minnesota and North Da-
kota, and the cost of the dinners for these guests is regularly
paid for by the Society funds.

During the year the scientific program was furnished on two
occasions by members of the Society. At three meetings the
program was presented by outside physicians from medical cen-
ters, all three this year being from the University of Minnesota.
One meeting was furnished in the form of a moving picture by
Squibb and Company, and one meeting was devoted to discus-
sion of local and state problems with all of the state officers as
special guest speakers. The December meeting was devoted to
election of officers and plans for the local Society for the com-
ing year.

One of the outstanding accomplishments of the Society this
year was the organization, financing and initiation of a pre-
payment medical plan for Cass County. This plan includes
only surgical, obstetrical and fracture benefits. It is sold by
and associated with the Blue Cross organization, and is called
The Physicians Service Plan. It is already in operation.

The Society’s balance sheet for the year shows evidence of
careful budgeting. There is just $9.00 more in our checking
account at the end of the year as compared with the end of
the previous year. Assets of the Society include two $500.00
G Bonds.”

Richland County District

The following is a resume of the proceedings of the Richland
County Medical Society for the year 1945, as submitted by
Dr. I. W. Kellogg, President:

"For your information relative to the Richland County Med-
ical Society activities, I may say that the vicissitudes of the war
disrupted our Society activities seriously. At the beginning of
the war, I had recently been elected President of the local
Society. However, our membership was quite small at that
time, and when two members went into the armed services and
a few others died, we discontinued holding regular meetings.
During 1945 our activities have been confined to active partici-
pation in regular staff meetings at our local hospital.”

Paul Burton, M.D., Councillor, First District

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Second District

The Devils Lake District Medical Society held but three
meetings in 1945. These meetings were for the most part well
attended, and some type of scientific program was provided at
each meeting. There has been as much interest shown in the
activity of the Society as might be expected during a war year.
I have noticed a tendency in the last three or four years for the
older men to gradually drop out of activity in the Society and
meetings to be attended largely by the younger men. Both
attendance and interest should improve over the coming year
with the return of a number of the medical personnel from the
armed forces.

John C. Fawcett, M.D., Councillor

Third District

The Grand Forks District Medical Society held eight regular
meetings during the past year.

The September meeting was held in Grafton as per custom,
with Dr. J. C. Swanson of Fargo, as guest speaker. The Oc-
tober meeting was at the Deaconess Hospital in Grand Forks,
with the entire day devoted to clinics and papers by Drs. Arlie
Barnes and George Eusterman of Rochester and Dr. C. D.
Creevy of Minneapolis. This meeting was especially well
attended.

Other guest speakers during the year were Dr. James Hanna
of Fargo, Dr. Dean Rizer of Minneapolis, Dr. John Adams of
Minneapolis, Dr. Bayard Horton of the University of Minne-
sota, and Drs. Charles Graham, Ralph Mahowald and Louis
Weller of Grand Forks.

We have a membership of 53, with only one physician in the
district not a member. New members of the Society are Drs.
Charles Graham, Kenneth Fritzell and Bernice Brown of Grand
Forks. There were two deaths during the year, Drs. H. W. F.
Law and E. C. Haagenson of Grand Forks.

The following officers were elected at the December meeting:
President, Dr. W. E. Dailey, Grand Forks; vice president, Dr.
L. J. Alger, Grand Forks; secretary-treasurer, Dr. E. A. Can-
terbury, Grand Forks; delegates to state convention, Drs. P. H.
Woutat, Grand Forks, and G. L. Countryman, Grafton; alter-
nate delegate, Dr. L. H. Landry, Walhalla.

The Traill-Steele Medical Society held three meetings during
the past year with the following officers in control: President,
Dr. O. D. Dekker, Finley; vice president, Dr. A. A. Kjelland,
Hatton; secretary-treasurer, Dr. Syver Vinje, Hillsboro; dele-
gate to state convention, Dr. O. A. Knutson, Buxton; alternate
delegate, Dr. R. C. Little, Mayville.

This Society has a present membership of eight, with one
man lost by removal from the district, and there are two appli-
cations for membership now on file.

Guest speakers during the year discussed the following sub-
jects: Carcinoma of the colon, Calculi in the urinary tract, and
Medical and Hospital service in North Dakota.

Every physician in this district is a member of the Society.

C. J. Glaspel, M.D., Councillor

Fourth District

The Northwest District Medical Society has held eight meet-
ings during the past year and all were very well attended. The
meetings have been held alternately at the Trinity Hospital and
St. Joseph’s Hospital with the Hospital Staff being responsible
for the programs.

We were unfortunate during the year in losing our Presi-
dent, who left to take postgraduate work, and the Vice Presi-
dent, who left the district and moved to San Antonio, Texas,
so we carried on in rather a temporary manner until the elec-
tion of officers, which was at the January 1946 meeting. The
following officers were elected: Dr. H. L. Halverson, president;
Dr. Mark I. H. Kaufman, vice president; Dr. J. L. Devine, Jr.,
secretary; Dr. A. R. Sorenson, delegate to the state society, and
Dr. D. J. Halliday, Kenmare, being a holdover. The alternate
delegates were Drs. M. T. Lampert and R. T. O’Neill, both
holdovers.

In March we had a very interesting meeting with Dr. Wall-
bank presenting a very excellent talk on the various phases of
tuberculosis and Dr. dayman of San Haven presenting an in-
teresting case of bronchopneumonia and gastritis.

In the April meeting, Dr. Gammel gave an outstanding
paper on the "Plating of Fractures.” At this meeting we had
a demonstration of the stethethrone and also had the pleasure

of having Dr. Garrison, who was home on leave, talk on some
of his experiences.

The May meeting was devoted to the report from our dele-
gate to the state meeting of the delegates held at Valley City.

The June meeting was well attended and there was more
discussion on the state meeting at Valley City. The scientific
part of the program was presented by Dr. Breslich, who gave
a very interesting talk on pulmonary embolism.

At the March meeting, 1946, Dr. Berton J. Branton of
Willmar, Minnesota, chairman of the Minnesota State Med-
ical Society’s Prepayment Medical Care Committee, talked
to our group at the 6:30 dinner meeting on what they were
accomplishing in the state of Minnesota and of the progress
that has been made in that state in regard to prepayment med-
ical care. At 8:15 P.M. Dr. Branton also addressed a public
meeting held in the Nurses Home and discussed the Wagner-
Murray-Dingell Bill, which presentation was very well received
by the laymen present.

We have now, in the Northwest District Society, 52 mem-
bers. Eight members have returned from military service and
are now in active practice. We have two new men in the dis-
trict who are not members of our state society as yet, but will
be as soon as their applications are acted upon. The general
response of the members to the increased dues of the state
society has been very favorable. We have lost, by death, one
of our old-time members, Dr. Anthon Flath of Stanley, who
practiced in Stanley for a number of years.

Archie D. McCannel, M.D., Councillor
Fifth District

Our society lost two members during the year, Dr. Fred
Brown, Valley City, by death, and Dr. S. A. Nesse, Nome,
who changed his residence to Minnesota.

We gained three new members during the year, Dr. W. H.
Gilsdorf from New England, North Dakota, Dr. G. C. Chris-
tianson from Sharon, and Dr. Paul T. Cook, who returned to
active practice from military service.

The membership of our society now is ten, all of whom prac-
tice in Valley City.

Only two meetings of our society were held during the year,
the annual meeting with election of officers in January, and a
special meeting in May to discuss and vote on the proposed
prepayment medical insurance plan.

Owing to our limited membership and the continued pres-
sure of work, no scientific meetings were held, but some of our
members attended meetings of the Cass County Society.

Officers elected for 1946 are as follows: President, Paul T.
Cook, M.D.; vice president, J. P. Merrett, M.D.; secretary and
treasurer, C. J. Meredith, M.D.; delegate to the state associa-
tion meeting, Paul T. Cook, M.D.; alternate, A. C. Mac-
donald, M.D.

Excellent harmony and cooperation prevails in our society.

C. J. Meredith, M.D., Councillor
Sixth District

The Sixth District Medical Society has held four meetings
during the past year. They were well attended and were pre-
ceded in each instance by a dinner.

The scientific programs were interesting and instructive and
were planned to be of special value to the general practitioner.
The programs during the year included: Film on "Otitis Media
in Pediatrics”; paper on "Amino-Acid Therapy,” by Dr. W. B.
Pierce; film on "Modern Nutrition,” by State Health Depart-
ment; paper on "Analgesia in Obstetrics,” by Dr. M. M. Heff-
ron; paper on "Functional Bleeding in Adolescence,” by Dr.
E. H. Boerth.

President J. F. Hanna was present at one of our meetings
and gave a very interesting talk on "Relief of Pain in Ob-
stetrics.”

The members of the Sixth District Society were especially
happy to welcome back from the armed services Dr. R. F.
Nuessle, Dr. R. W. Henderson, Dr. R. B. Radi, Dr. Ralph
Vinje, and Dr. C. H. Arneson. An interesting program deal-
ling with war experiences in the various theaters of war was
presented by this group of returning physicians.

There are now 58 paid-up members, including two new mem-
bers, Dr. William M. Smith from Nassau County Medical So-
ciety, New York, and Dr. E. H. Boerth, who transferred from
the Cass County Medical Society. Two members have with-
drawn and six members have not yet paid their 1946 dues.

September, 1946

295

The officers elected for the ensuing year are: President, Dr.
R. B. Radi; vice president, Dr. C. J. Baumgartner, and secre-
tary-treasurer, Dr. W. B. Pierce.

The affairs of the society have been efficiently conducted and
good fellowship has prevailed throughout the year.

N. O. Ramstad, M.D., Councillor
Seventh District

Only two meetings of our County Medical Society were held
this past year because of war conditions, but we hope to im-
prove on this record from now on.

One meeting was held April 26, 1945, at which time Presi-
dent Wicks addressed the Society on the subject of medical
economics. After considerable discussion the Society expressed
sympathy with the idea of a medical service plan covering
catastrophic illnesses.

On February 14, 1946, a meeting was held at which time
officers for the ensuing year were elected, and dues for the
County Society set at $10.00 a year, which together with the
state dues made a total of $45.00. To date 12 members have
paid dues for 1946, as against 18 last year.

One of our esteemed members has passed on during the year.
Dr. H. O. Grangaard of the State Hospital Staff. Dr. Richard
Nierling has returned to the Society after more than four
years’ service to his country.

Joseph Sorkness, M.D., Councillor
Eighth District

One meeting of the Southern District Medical Society was
held during the year. This at Ellendale January 17, 1946, with
six members present. Drs. J. D. Alway and Owen King of
Aberdeen were the speakers. Dr. Alway gave a very interest-
ing talk on "Common Disorders of the Eye, Ear and Nose.”
Dr. Owen King gave an instructive paper on "Fractures” with
particular emphasis on fractures of the femur.

Several of the members have attended meetings of neighbor-
ing societies during the year.

F. W. Fergusson, M.D., Councillor

Ninth District

The Tri-County Medical Society held two meetings during
1945 and to this date, one in 1946.

Discussion was practically limited to Medical Economics.
Having supported the plan of the Medical Economics Com-
mittee before the state meeting, the Society showed its consis-
tency by voting at the 1946 meeting to adopt the Cass County
Plan.

Work of the Society has been hampered by war conditions
and bad roads. However, the meetings have been interesting
and successful, and all members are in good standing.

A. E. Westervelt, M.D., Councillor

Tenth District

During the year the Southwestern District Medical Society
has held four meetings, all of which have been well attended.
We have had some outstanding programs, all contributed by
members of our own Society.

We are very happy to report that two of our members have
returned from service in the armed forces, which gives us a
membership of 20, all of whom have paid their dues. Dr.
W. H. Gilsdorf, formerly of New England, has moved to
Valley City.

Throughout the past year there has been a great deal of
interest shown in medical economics. There has been no dis-
sension and a universal feeling of good fellowship has prevailed.

W. H. Gilsdorf, M.D., Councillor

REPORTS OF STANDING COMMITTEES

The following reports of the standing committees were re-
ferred to the reference committee on reports of standing com-
mittees.

Medical Education

Your Committee on Medical Education would call your
attention to reports of earlier years which indicate the plan,
scope, and needs of the School of Medicine at the University
of North Dakota, although these items are pretty well known
to all. Since the meeting of last year, the School has again
remained in continuous session, the accelerated program de-
manded by the war effort. Classes have remained of the same
size but admissions have come approximately every nine months,
many of the students simply assigned to us by the ASTP or

the Navy V-12. The work of transferring has gone on as usual.
The admissions under the accelerated program had brought
us around to the regular or pre-war opening date, in the fall
of 1945. Our present classes will finish the regular year’s pro-
gram in June, 1946. The school has decelerated and will not
be in operation during the summer months of 1946. It could
be said that the accelerated program — which has run for ex-
actly three years, by accepting an entering class every nine
months and considering three terms of thirty-six weeks each
an academic year — has enabled the School of Medicine to
complete four academic years in the three calendar years.

As reported last year, the Legislative session of 1945 appro-
priated $250,000 for a building to house and to make better
facilities for the work of the school as it is. The difficulties
of getting material, labor, etc., caused the Board of Higher Ed-
ucation to postpone any thought of building in the year of 1945.
Because of the continuation of the same difficulties, it is ex-
tremely doubtful whether anything can be accomplished toward
building, except a possible excavation, in the year of 1946.

The 1945 session also passed Senate Bill 115, as reported
last year. This established a Medical Center at the University
and provided for the Medical Center Advisory Council. The
Council has had two meetings, one in August, 1945, and the
other in January, 1946. Much has been accomplished in the
way of discussion and planning, but only progress can be re-
ported at this time.

H. E. French, M.D., Chairman
Necrology and Medical History
1946

In continuance of the traditions of our profession we pause
in the activities of life to sincerely pay our respect to those of
our colleagues who have left our ranks for the Great Beyond
since last we met.

We mark well their worthiness and their accomplishments;
their faithful and ethical cooperation and their devotion to
our profession.

May those who mourn accept our tendered sympathy with
the knowledge that the lives of their loved ones will ever fur-
nish inspiration to those of us who still remain to carry on.
IRA D. CLARK

Dr. Ira D. Clark, 77, practitioner of Fargo and a long-time
resident of the state, died July 22, 1945, at his lake cottage
near Shoreham, Minnesota. Dr. Clark was a native of Berlin,
Wisconsin. He received his medical education at the Chicago
Homeopathic College, graduating in 1895. He was licensed the
same year and began practice at Harvey, where he remained
for twenty-seven years. While at Harvey, Dr. Clark served for
several years as president of the Tri-County Medical Society.
He was a prominent pioneer physician. In 1925 he moved to
Fargo to continue his professional life. He practiced at Milnor,
North Dakota, from 1939 to 1942, when he again returned
to Fargo. He was a member of the Masonic bodies and the
Shrine. Surviving are his wife, four sons, Cant. Ira D. Jr.; Lt.
William E.; Henry S., stationed in Roswell, New Mexico; and
Frank D. of Port Washington, New York, and Lt. Lucille
of the U. S. Navy; also a brother, Edward E. Clark of Port-
land, Oregon, and a half-brother, Jud Rollins of New York.
CHARLES H. PATTERSON

Dr. Charles H. Patterson, 60, of Fargo, and a member of
the staff of the Veterans Administration Facility at Fargo, died
August 8, 1945, following a heart attack suffered three days
previously while at his cottage on Pelican Lake, in Minnesota.
He died in Fargo at the Veterans Hospital. Dr. Patterson was
born in Moorhead, Minnesota, and graduated from Hamline
University, Medical Department, with the class of 1908. He
was registered in North Dakota in the same year and began
his medical career at Alice, North Dakota. Later he practiced
at Enderlin and Edinburg, both in North Dakota, and in 1911
he took over his father’s practice in Barnesville, Minnesota.
Here he remained until 1929, when he joined the Veterans
Administration. He served this organization in Washington,
D. C., Boise, Idaho, and Minneapolis, Minnesota, coming to
Fargo in 1934. Dr. Patterson served as a Lieutenant in World
War I. He was a member of the American Legion, Masonic
bodies, Scottish Rite, Eastern Star and El Zagel Temple of
Fargo. Survivors are Mrs. Patterson, two daughters: Lt. Anna
Jane, U. S. Navy, Mrs. Marjorie McClung, Los Angeles; a

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The Journal Lancet

sister, Mrs. Olga Anderson, Seattle, and an uncle, Dr. T. C.
Patterson of Lisbon, North Dakota.

JOSEPH A. SMITH

Dr. Joseph A. Smith, 61, died August 13, 1945, in a Minot
hospital, following a heart attack. Dr. Smith was a native of
Ellendale, North Dakota, graduated from George Washington
University, 1907, and was licensed in North Dakota in 1909.
In his youth, he was a page boy in the House of Representa-
tives, Washington, D. C., and was well acquainted with mem-
bers of Congress from North Dakota. He was located in prac-
tice in York, North Dakota, for two years. In World War I,
Dr. Smith served as a Captain, MC, and following his dis-
charge, was associated with Dr. A. D. McCannel in practice
at Minot. For many years he was in practice in Noonan, North
Dakota, and was head of the community hospital at that city.
Dr. Smith was active in civic affairs. Shortly before his death,
he had relocated in Minot with the Northwest Clinic as a spe-
cialist in eye, ear, nose and throat work. He was a member of
the Masonic lodge of Crosby; Kem Temple, Shrine, of Grand
Forks; Scottish Rite of Minot and the Elks lodge of Minot.
Dr. Smith is survived by his wife, a son, Lt. Col. Larry Smith;
a son, Aird, and a daughter, Mrs. Souren Avakian of Phila-
delphia; his mother, Mrs. Ed. A. Smith of Ellendale, North
Dakota; five sisters and two brothers, including Lt. Com.
Charles E. Smith of Seattle.

OTTO WILBER MC CLUSKY

Dr. Otto Wilber McClusky, 71, of Chemawa, Oregon, passed
away August 16, 1945, in the Deaconess Hospital at Salem,
Oregon. Death was due to a cerebral hemorrhage. Dr. Mc-
Clusky was a graduate of Rush Medical College with the class
of 1905. He was licensed to practice in North Dakota in
1906. He was located in Carrington, where he was instrumental
in building the hospital. He served in World War I, and was
discharged with the rank of Major. After locating in the west,
he was connected with the Civilian Conservation Corps and also
was in charge of a hospital in the Indian Service.

FREDERICK CHARLES HARRIS

Dr. Frederick Charles Harris, 75, died September 15, 1945,
at Cando, North Dakota. Dr. Edams was born in Brant
county, Ontario, September 25, 1870. He was educated at
Brantford Collegiate Institute and graduated from Trinity Uni-
versity Medical College in the class of 1895, internship at
Toronto General Hospital in 1895-96. He came to North
Dakota and was licensed in July, 1896, and practiced for three
months in Hillsboro in partnership with the late Dr. Haagen-
son. He settled in Cando in October, 1896, where he was
joined in partnership with Dr. John G. Lamont in 1901, under
the firm name of Drs. Harris and Lamont. He continued in
practice until about 1920, when he retired to devote his entire
attention to large real estate investments in Towner and Ram-
sey counties. Dr. Harris was formerly coroner and president
of the Board of Health of Towner county, and had been a
director of the Tuberculosis Sanatorium at San Haven. His
death was due to coronary thrombosis with only a few hours
illness. He has a son, Robert, who is a Flight Surgeon with the
U. S. Army; another son, Frederick, a dentist with the U. S.
Navy at San Diego; and the eldest son, Richard, is a geologist
for several years employed with the Atlantic Oil Company with
headquarters in Philadelphia. A daughter, Lucille, is at home
in Cando. Dr. Harris was the youngest in a family of twelve,
a few of whom are still living in Brant county. Dr. Harris
arrived in Towner county before the early immigration, and
for many years was a well-tried pioneer physician of that section.

CHARLES SUMMERS MARSDEN

Dr. Charles Summers Marsden, 72, passed away October 13,
1945, in San Diego, California, where he had resided since
1922. Dr. Marsden was a graduate of the University of Mi-
chigan, class of 1903, and was licensed the same year in North
Dakota. He located at Carrington where he practiced until
his removal to Grand Forks in 1906. Having splendid training
in eye, ear, nose and throat work, he limited his practice to
this specialty during his remaining years in North Dakota. Dr.
Marsden was a charter member of the North Dakota Academy
of Ophthalmology and Otolaryngology, which was formed in
1919

FREDRICK BROWN

Dr. Fredrick Brown, 65, died November 13, 1945, at his
residence in Valley City. Death was due to a heart ailment
from which he had suffered for a number of years. He con-
tinued in practice as a specialist in eye, ear, nose and throat
work, however, until shortly before the fatal attack. Dr. Brown
was graduated from the College of Physicians and Surgeons at
Chicago in 1905, and was licensed the same year in North
Dakota. He had practiced at McClusky until coming to Val-
ley City in 1927. Dr. Brown was a member of the Shrine and
the Modern Woodmen of America. He is survived by his wife,
one daughter, Virginia, Mrs. Charles T. Trane of Lompoc,
California, and four sisters: Mrs. Alfred Shaken, Mrs. Marie
Shaleen, both of Chicago, Mrs. Violet Pierce of Morris, Illinois,
and Mrs. Walter Watson of West Franklin, Illinois.

HENRY W. F. LAW

Dr. Henry W. F. Law, 74, died December 2, 1945, in a
hospital in his home city of Grand Forks. His death resulted
from a cerebral hemorrhage. He was a native of Brock, On-
tario, and graduated in 1904 from the Detroit Medical College
and was licensed in North Dakota in 1906. Dr. Law practiced
at Hannah, North Dakota, for a number of years, relocating
in Grand Forks in 1913, where later he became associated with
the Grand Forks Clinic. Dr. Law had held the position of
Chief of Staff of the Deaconess Hospital and had served two
terms on the Grand Forks City Commission. Survivors include
a son, Cmdr. Frank Law of the U. S. Navy; a daughter, Mrs.
Carlton A. Pederson, Burbank, California; two brothers, D. N.
Law, Edmonton, Alberta, and John Law, Boissevain, Manitoba,
and a sister, Mrs. Charles Beckerjeck, Werner, North Dakota.

ANTHON FLATH

Dr. Anthon Flath, 81, died December 4, 1945, at Stanley,
North Dakota, after a long period of ill-health. He had been
a practitioner in North Dakota for 47 years. Dr. Flath was a
native of Ontario and was graduated from the University of
Toronto in 1892. He was licensed in North Dakota in 1893.
He practiced his profession at Church’s Ferry from 1898 to
1912, when he moved to Stanley. Dr. Flath is survived by his
wife, two daughters, one sister and two brothers. His daugh-
ter, Olive, is a resident of Stanley, as also are two nephews,
Dr. M. G. Flath, physician, and Dr. G. O. Flath, a dentist.

WILLIAM L. GORDON

Dr. William L. Gordon, 72, of Washburn, passed away in
a hospital at Bismarck, December 9, 1945. Death was due to
heart failure following an attack of influenza. Dr. Gordon was
a native of Kentucky, graduating from the University of
Louisville in 1894. He was licensed in North Dakota in 1902.
He came to North Dakota in 1901 and located at Steele,
where he remained for ten years. He practiced in Underwood
for two years and then relocated at Washburn, where he prac-
ticed until his last illness. He held the office of health officer
and county physician for over twenty-five years. As family phy-
sician and friend, Dr. Gordon will be missed by all in a wide
territory. Dr. Gordon was a member of the Elks Lodge of
Bismarck and the Masonic Lodge of Washburn. He is sur-
vived by his wife, daughter Mary Agnes, an employee of the
State Health Department of Bismarck, his step-mother, Mrs.
R. D. Gordon, and four sisters, all of Winchester, Kentucky.

HENRY OSWALD GRANGAARD

Dr. Henry Oswald Grangaard, 64, died February 10, 1946,
at Jamestown. His death was caused by a heart attack. Dr.
Grangaard was a native of Cass county, attended Luther Col-
lege of Decorah, Iowa, and was graduated from the School of
Medicine, University of Minnesota, in the class of 1908. After
practicing at Newark, Illinois, he came to North Dakota in
1910, locating at Douglas, and remained there until 1921, when
he moved to Ryder. He was licensed in 1910. In 1943, Dr.
Grangaard located at Proctor, Minnesota. On July 1, 1944, he
returned to North Dakota, locating at Jamestown, where he
became a member of the staff of the State Hospital. He was
a member of the Lutheran Church. Survivors are his widow,
two sons: Donald H. and Lawrence B., recently discharged
from the Army; his mother, Mrs. Jorand Grangaard; three
brothers, three sisters and a grandson.

September, 1946

297

LEONARD BUSSEN

Dr. Leonard Bussen died at the home of his son in St. Paul,
early in March, 1946. He graduated from the University of
Minnesota. Dr. Bussen was a practitioner of Valley City in
the middle nineties, afterwards practicing at Richardton before
leaving the state. Survivors are his wife, a son, Leonard, and
a daughter, Nita.

MARTIN DANIEL WESTLEY

Dr. Martin Daniel Westley, 72, pioneer physician of Coopers-
town, passed away in Northwestern Hospital, Minneapolis,
March 28, 1946. He died from complications following a sur-
gical operation. Dr. Westley was a native of Norway, and
came to this territory with his parents at the age of nine. His
early education was obtained in Griggs County schools and
Red Wing Academy of Minnesota. He taught school for a
few years, then attended Hamline University, St. Paul. He
took his medical education at Jefferson Medical College in
Philadelphia, graduating with the class of 1904. He was
licensed to practice in July of the same year. Dr. Westley
returned to his home town to start his medical career and
there he remained in service to the end of his allotted time,
with the exception of two years spent in the Medical Corps of
the Army in World War I, from which he was discharged as a
Captain. Dr. Westley was civic-minded and contributed his
time and interest as a member of the school board; as the first
scoutmaster; as an elder of the Presbyterian Church; medical
officer of county and city, and to many other positions. He
belonged to the American Legion, the Masonic and Eastern
Star lodges. Survivors are Mrs. Westley; a daughter, Ruth
Ann, student at Pomona College, Claremont, California; three
sons: Richard O. of Chicago, Bruce H. of Little Common,
Massachusetts, recently discharged from the army, and Captain
Kent F., with the Army Medical Corps in Germany; a brother,

O. C. Westley of Pasadena, California, and a sister, Anna,
of Minneapolis.

F. L. Wicks, M.D.

G. M. Williamson, M.D., Co-Chairmen

Public Policy and Legislation

The following is a report of the Committee on Public Policy
and Legislation:

The Committee on Public Policy and Legislation has not been
called together this year as there have been no matters of im-
portance called to our attention.

We have kept closely in touch with the program of Compul-
sory Health Insurance measures and also with the activities of the
North Dakota State Health Planning Committee, to see if we
could be of any help in either instance in clarifying the State
Medical Society’s position in these matters. So far there does
not seem to be anything we can do until some of the problems
are investigated further. We do feel that some of the groups
that have been very active, are beginning to get a better idea
of medical needs and the solving of the problems of taking care
of them.

We specifically approve the policy of the report of the Com-
mittee on Medical Economics relating to negotiations with the
Veterans Administration and we feel that our State Associa-
tion should cooperate in every way, with the Veterans’ Admin-
istration, as they are experiencing some difficulty in taking care
of their program and will require the fullest cooperation of the
members of our Association.

Archie D. McCannel, M.D., Chairman
Public Health

A meeting of the Public Health Committee of the State
Medical Association was held in Bismarck, Sunday, March 24,
with the following present: Dr. Sam Chernausek, Dickinson;

Dr. H. D. Huntley, Kindred; Dr. Mary Soules, New Eng-
land; Dr. William Smith, Bismarck (guest) ; Dr. G. F. Cam-
pana, Bismarck, chairman.

The group went on record as favoring:

1. Extension of immunization in the state with the stipula-
tion that the Medical Society instruct their members so they
would be willing to use whatever immunizing materials the
Public Health authorities can furnish them;

2. Participation in the North Dakota Tuberculosis Program
by all members of the medical profession and Health Officers’
Association;

3. Further education of the lay public and physicians in
tuberculosis and recommend a refresher course at the Univer-

sity of Minnesota Continuation Center and urge the Anti-
Tubercuolsis Association to conduct such a course;

4. Recommending to the State Medical Association that they
make available to the State Department of Health a roster of
speakers. These physicians could then be called upon by the
State Department of Health whenever needed to give talks in
their respective areas;

5. Recommending that the State Medical Association and/or
District Medical Societies or individuals therefrom submit ma-
terial such as reports of medical society committee meetings,
to the newly organized quarterly publication of the State De-
partment of Health, North Dakota Health News, for distribu-
tion in North Dakota;

6. Recommendation to the Venereal Disease Committee that
they consider the establishment of the rapid treatment center
plan and state that we as a committee approve the establishment
of such a plan;

7. Approval of the establishment of district health units and
recommend that the State Medical Association cooperate in
establishing the same;

8. Recommending to the Venereal Disease Committee that
they make known to the medical profession those services
offered by the State Department of Health regarding a new
program of follow-up of delinquent patients and contacts so
that physicians may avail themselves of the benefits accruing
therefrom;

9. Recommending to the medical profession that they become
familiar with such proposals as President Truman’s Health
Program; those bills dealing with hospital construction; mater-
nal and child care, et cetera, and be prepared to evaluate and
discuss these needs at the state meeting.

G. F. Campana, M.D., Chairman
Official Publication

Our relationship with the Journal-Lancet has been satis-
factory. The editor and publisher have cooperated in publish-
ing the papers presented at our district and state meetings, and
the news items from North Dakota have been interesting and
informative. The transactions of the 1945 meeting of the
House of Delegates were voluminous, but the Journal Lancet
published them completely, in spite of obvious difficulties, such
as paper shortage.

L. W. Larson, M.D., Chairman

Tuberculosis

The activities of the Tuberculosis Committee of the State
Medical Association of North Dakota during the past year was
confined to cooperation with the State Health Department, and
the North Dakota Antituberculosis Society, in the formulating
of plans for the survey of the public of North Dakota for
tuberculosis. The representatives of the committee have been
in numerous conferences with the above organizations, and we
are pleased to report unusual and satisfactory cooperation of
all of these agencies, with the result that the program has been
launched, and will be extended as rapidly as equipment is
available.

At the present time a portable X-ray unit is being used in
some of the state institutions. The procedure is as follows:
The films are read by the roentgenologists of the state, who are
paid for their services. When suspicious pathology is found,
the case is referred to his or her private physician and from
then on is handled as a private patient. These cases must have
a thorough physical examination and 14x17 films of the chest
taken. These are to be interpreted by representatives of the
state sanatorium. In case of indigence, the State Antitubercu-
losis Society will pay for the examinations. Before the Com-
mittee recommended this program, the entire medical profes-
sion was canvassed and an overwhelming vote in favor of the
program was received. There has been concurrence at all times
of the members of the committee in working out the details of
the program. Matters are satisfactory to the roentgenologists,
to the physicians of the state, and to the committee.

This development is the consummation of an ideal toward
which the committee has been working for many years, and
undoubtedly is a great forward step in public relations and pub-
lic benefaction for the State Association. We, as members of
the committee, would like the continued support of the House
of Delegates and the physicians at large in this program. We
trust that nothing will be done which will jeopardize the pro-
gram.

J. O. Arnson, M.D., Chairman

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The Journal Lancet

Cancer

The activities of the Committee on Cancer during the past
year have been confined to the program of the North Dakota
Division of the American Cancer Society. The American Can-
cer Society has broadened its program and has recently re-
organized (March 28, 1946) so that its control is on a demo-
cratic basis and each state will have a voice in the affairs of
the society. The program of the society includes education,
research, and service. The educational work is carried on
through the press, radio, and descriptive literature. The re-
search program of the society is controlled by a special com-
mittee on growth, which has been named by the National Re-
search Council. This council was primarily responsible for the
miraculous scientific achievements of the United States during
World War II. Panels on chemistry, biology, genetics, etc.,
have been named by the committee on growth, and their mem-
bership includes foremost specialists in their respective fields.
The committee on growth is making an exhaustive survey of
cancer research developments to date and of the facilities for
research in all types of institutions in this country. It will
allocate funds to institutions which apply for aid to carry out
a program of research which is approved by the committee on
growth. This set-up insures all contributors to the research
fund of the American Cancer Society a coordinated effort
which, we hope, will result in conquering cancer.

The service program of the society is a new development.
Surveys of the facilities available for the diagnosis and treat-
ment of cancer are being made in every state. Problems such as
the education of the family physician in the early recognition
of cancer, and the provision of adequate diagnostic, treatment,
and hospital facilities for cancer patients, will differ in the vari-
ous states; the society is pledged to assist wherever deficiencies
are known to exist. So-called "Cancer Detection Clinics,” de-
signed to provide the citizen, who considers himself, or herself,
entirely well, with a facility in which cancer can be detected, are
being developed in many states. Your Committee on Cancer
is studying this problem, particularly from the standpoint of
the desirability and practicability of developing such clinics in
North Dakota. The House of Delegates of the American Med-
ical Association, which met in Chicago last December, approved
the following recommendations of its Council on Medical Serv-
ice and Public Relations:

1. A cancer detection, cancer prevention or well-person clinic
was defined as designed to detect abnormalities, not producing
symptoms sufficient to send the patient to the doctor. These
clinics do not diagnose or treat disease; and

2. No such clinics shall be established in any community
without the approval of the County Medical Society.

Anticipating the development of a state-wide program of
service to cancer patients to conform with that of the American
Cancer Society, each District Society was urged, last December,
to authorize and appoint a committee on cancer. Efforts are
being made by the American Cancer Society, in cooperation
with the American Medical Association and the American Col-
lege of Surgeons, to develop standards for detection clinics.
These standards will be made available to each District Society
as soon as they have been completed. It is evident that they
cannot apply specifically to conditions which may prevail in
each County or District Society throughout the nation, but
they will serve as a broad basis of policy covering the establish-
ment and maintenance of detection clinics.

RECOMMENDATIONS

1. That the House of Delegates of the North Dakota State
Medical Association approve in principle the objectives of the
American Cancer Society.

2. That the House of Delegates of the North Dakota State
Medical Association approve the development of a program of
service to cancer patients, including the development of cancer
detection clinics, established only with the approval of the local
District Medical Society in conformity with broad principles of
policy which will be forthcoming from the Committee on Can-
cer of the North Dakota State Medical Association.

L. W. Larson, M.D., Chairman
Fractures

Although there was no formal meeting of the Fractures
Committee during the year 1945, the members of the com-
mittee have endeavored to carry out the same program as out-
lined by us during the past several years.

R. H. Waldschmidt, M.D., Chairman

Maternal and Child Welfare

To the House of Delegates of the North Dakota State Med-
ical Association in annual meeting in Bismarck, North Dakota,

May, 1946:

Since the E.M.I.C. program became effective in North Da-
kota, January 1, 1944, and to March 12, 1946, 2648 wives of
service men and 1181 children of service men have been cared
for under this program. Your Committee believes that the
peak load under this program has passed. The physicians of
North Dakota have cooperated well with the Maternal and
Child Hygiene Division of the North Dakota State Health
Department in completing the reports required and the State
Health Department is to be congratulated upon having reduced
to a minimum the inevitable forms which had to be completed
in handling these cases and for the promptness with which they
have been handled. Your Committee has been consulted fre-
quently in its advisory capacity to the State Health Department
regarding E.M.I.C. and there never has been any disagreement
between us and the Division of Maternal and Child Hygiene.
Much of the credit for expediting this work must go to Dr.
George F. Campana, the state health officer, who, in spite of
the many other duties he has, has devoted much extra time to
this division.

In 1940 North Dakota had established a low maternal death
rate of 1.7 per 1000 live births. In 1941 it had risen to 2.6.
In 1942 it was 2.5 and in 1943, 2.9. It is significant to note
that in 1943 deaths from obstetric hemorrhage led all other
causes of maternal deaths. In 1944 the rate had dropped to
1.8 and the provisional rate for 1945 is 1.1 per 1000 live
births, the lowest ever recorded for North Dakota. In 1943
there were listed five deaths from ectopic gestation and eight
deaths from puerperal hemorrhage. In 1944 there were no
deaths from ectopic gestation and in 1945 there were two; while
for puerperal hemorrhage there were six deaths listed in 1944
and three in 1945.

The first dried human plasma, prepared by the State Plasma
Bank at the University of North Dakota, had passed all of its
tests by August 27, 1944. It is interesting to note the use of
plasma in obstetric patients in North Dakota during the first
year of operation of the bank, from August 27, 1944, to
August 27, 1945. These are given in the table.

Ectopic pregnancy with severe hemorrhage ...

Placenta previa

Postpartum hemorrhage .... ..

Patients

Units

Abruptio Placentae .... ..

Cesarean section .. _

Abortion ...

Vaginal bleeding ....

Total

114

171

During this same period, a total of 663 patients received
North Dakota made plasma, thus it will be seen that about
18 per cent of them were obstetric patients.

Your Committee does not attempt any correlation between
the foregoing table and the reduction of the maternal deaths
from ectopic gestation and puerperal hemorrhage in 1944 and
1945 for these are not the only obstetric conditions in which
hemorrhage is a factor; but we do believe that the Plasma Bank
program has been very effective in reducing deaths from ob-
stetric hemorrhage and we urge that it be continued.

Your Committee recommends a continuation of the program
of immunization against diphtheria and pertussis. Outbreaks of
diphtheria still occur in North Dakota and, while they have
been comparatively mild in recent years, deaths have occurred
and the menace of the disease is ever present, particularly in
young children who have not been immunized. Pertussis is
particularly dangerous during the first year of life. Intensifica-
tion of our efforts to immunize against these diseases is par-
ticularly important in a Child Welfare program. Smallpox has
been very infrequent in North Dakota recently. This may be
properly attributed to the large number of vaccinations which
were done when the disease assumed almost epidemic propor-
tions a few years ago; but your Committee would point out
that another generation of children have been born since that
time, many of whom have not been vaccinated, and that these
unprotected children offer a fertile field for smallpox. We rec-

September, 1946

299

ommend that increased emphasis be placed on smallpox vac-
cination.

Your Committee recommends that before any transfusion of
a pregnant woman be done, the Rh factor of both donor and
recipient be known.

Your Committee further recommends that the determination
of the Rh factor of both applicants for marriage licenses be
encouraged and that the Division of Laboratories of the North
Dakota State Health Department be requested to make Rh de-
terminations at the request of the physicians of North Dakota.

John H. Moore, M.D., Chairman
Crippled Children

There have been no official meetings of this committee during
the past year. A meeting was scheduled in December 1945,
but was cancelled by the State Department of Crippled Chil-
dren, because of bad weather. No subsequent meeting has been
called. A. R. Sorenson, M.D., Chairman

Pneumonia

The Pneumonia Control Committee met November 25, 1945,
at 10:00 o’clock A.M., at the Gladstone Hotel, Jamestown,
North Dakota. Present at the meeting were the chairman,
O. W. Johnson, M.D., of Rugby; W. H Gilsdorf, M.D., of
Valley City; and G. F. Campana, M.D., state health officer.

Surgeon A. B. Price of the U. S. Public Health Service was
unable to attend the meeting. Recommendations to be brought
before the meeting were received from Medical Director Estella
Ford Warner. Doctor Warner is also with the U. S. Public
Health Service in the position of Medical Director for Dis-
trict No. 7. Her recommendations were read before the meet-
ing and acted upon.

A resume of the Pneumonia Control Program from Decem-
ber 1939, when it was put into operation, to the present time
was read, and the following actions were suggested:

Doctor Johnson, acting as chairman of the meeting, sug-
gested the elimination of the typing stations throughout the
state with the exception of four; namely the Public Health
Laboratory at Bismarck, the Public Health Laboratory at Grand
Forks, the Fargo City Laboratory at Fargo, and the First Dis-
trict Health Unit at Minot.

It was suggested that we leave the sub-stations as they are
in order that they may continue to act as supply depots. As
before upon the request of the physician sulfamerazine, sulfa-
thiazole and sulfadiazine will be furnished. Also serum will
be furnished upon request.

Pleural effusion and empyema. It was suggested in cases of
pleural effusion with empyema in pneumonia that penicillin be
injected directly into the pleural cavity. 20,000 to 40,000 units
every hour until the fever is normal, parenterally given. When
empyema develops use 2500 units after each aspiration of chest
if organism is present.

Pneumococcic meningitis. It was suggested that no more than
10,000 units of penicillin per dose be administered intrathecally,
using extreme caution as there is great danger of a myelitis
developing.

The Pneumonia Control Committee feels that physicians of
the state are not availing themselves of services the State Health
Department is offering them, and urges that they make more
use of these services.

The maximum number of X-rays remains at three but it is
recommended that in exceptional cases the physician be author-
ized by the State Health Department to use his own judgment
in taking further X-rays.

The Committee wishes to advise that small typing kits are
now available through commercial channels for the use of
those physicians who wish to carry a kit with them. These are
advantageous, especially in making country calls.

Delacillin* This drug is recommended particularly for use in
cases of pneumonia in children. Extreme care must be taken in
warming so as not to separate the penicillin from the beeswax.
1 cc. vial of 300,000 units is recommended, liquefied and inject-
ed with a large 18-gauge needle, to be given immediately as the
beeswax solidifies quickly. In giving this to children it saves
waking them every three hours for an injection since only one
such injection daily is required.

Doctor Johnson requested that the Public Health Labora-
tories at Grand Forks and Bismarck keep an amount of delacil-

*Name of product since changed to Penicillin in Oil and Wax

— [Ed.]

lin on hand. It is difficult for physicians to get a supply at
present and in being able to get it from the Laboratories, the
physician could either replace the drug or pay for it outright.
Delacillin can be purchased from Squibbs at present.

The Committee agreed that the State Health Department
pay each physician a fee of 25c for each complete case report
of pneumonia, whether the case falls under the pneumonia con-
trol plan or not. This is to become effective January 1, 1945.

O. W. Johnson, M.D., Chairman
Report of Committee on Medical Economics

The past few years, having been prosperous years in North
Dakota, economic problems have not loomed as largely as in
previous years.

Our relationship with the Welfare Board and the Relief
Organizations have been most cordial and there has been no
problem in that field.

We have not had any dealings with the Farm Security Ad-
ministration; however, information obtained from other states
has been to the effect that plans have been uniformly failures
and in most instances have been discontinued. The present
medical director of the F.S.A., Doctor Mott, recently read a
paper in Chicago in which he advocated passage of the Wagner-
Murray-Dingell Bill. As Doctor Mott is a member of the
U.S.P.H.S., presumably he reflects the official opinion of this
government agency.

At the present time, we are concerned with phases of med-
ical practice having some economic basis not necessarily con-
nected entirely with the ability of the patient to pay for med-
ical care. We are concerned with improvement in distribution
of medical care and its cost. You are all familiar with pro-
posals in this field which are: (1) Voluntary prepayment insur-
ance controlled by the profession. (2) Compulsory insurance
as proposed in S-1606, the Wagner-Murray-Dingell Bill.

Since January 1, the chairman of this Committee has attend-
ed three national meetings dealing with various phases of this
subject. At a meeting of the National Physicians Committee,
all proposed federal legislation was carefully studied and meas-
sures were proposed whereby the profession could express its
opinion on proposed bills. He also attended the National Con-
ference on Medical Care where farm leaders, notably Mr.
Jones, vice president of the Farm Bureau, spoke for the farm
organizations. The vice president of the A. F. of L. gave a
vehement discourse favoring compulsory federal insurance. The
American Medical Association sponsored a meeting in March
dealing with the subject of improvement of rural medical care.
This meeting was addressed by a number of farm organization
leaders who seemed to have a real grasp of the situation and
were all in favor of accomplishing improvement by the process
of evolution rather than by revolution. We have been very
much impressed with the sensible viewpoint of farm leaders and
believe that the profession should cooperate with these people
and it will be to the advantage of both ourselves and farm
families.

PROPOSED FEDERAL LEGISLATION

At the present time in the Congress there are a number of
bills dealing with medical subjects. Most prominent of these is
the Senate 1606, or the Wagner-Murray-Dingell, which is in
two parts, Title One and Title Two. Title One is concerned
with Federal grants in aid to states for various health services
such as maternal and child health service, health service for
crippled children and care of indigents. The American Med-
ical Association in general favors these provisions. Title Two
is the portion of the bill to which we are all definitely opposed.
This provides for complete medical service under a Federal In-
surance plan. At the present time, hearings are being held on
this bill limited largely to those who are favorable to it. Re-
ports of the hearings will be available in the Journal of the
A M. A. This bill definitely will not be passed this year, but
will reappear next year.

The second bill of interest to the profession is Senate No.
1318, the Pepper Bill. The Pepper Bill provides for the contin-
uation of the E.M.I.C. program among the civilian population.
If its provisions were put into effect, any pregnant woman in
the United States would be entitled to the full maternity care
and any person under the age of 21 years would be entitled to
complete medical care. This bill is probably sponsored by Dr.
Elliott of the Children’s Bureau. While this bill is unlikely to
pass this year, it has more chance of passage than the Senate
1606.

300

The Journal Lancet

The third bill is for grants in aid to the states for the pur-
pose of hospital construction. There is some doubt at this time
whether this bill will pass or not. The appropriations committee
of Congress is becoming increasingly critical of legislation of
grants in aid to the states type. There seems also to be a great
deal of opinion developing among the states that they will be
much better off if they take care of their own needs and do
not accept Federal aid.

We would urge all physicians to take every opportunity of
getting in touch with their representatives in the Senate and
House in order that they may express their views on impending
legislation. Legislators are extremely interested in what the folks
back home think and are very receptive to suggestions from the
profession.

VOLUNTARY PREPAYMENT INSURANCE

The Cass County Medical Society has put into operation in
Cass county, the prepayment medical plan developed last year
by this Committee.

At the present time they are operating through the Blue
Cross, offering a contract to the Blue Cross subscriber groups.
Their by-laws provide that any district medical society in North
Dakota may join and participate in this prepayment plan if
they wish to do so.

The Committee on Medical Economics has passed a resolu-
tion stating that they approve the plan developed in Cass
county and advise other district medical societies to join the
North Dakota Physicians Service if a majority of their mem-
bers so desire.

We do not recommend to the House of Delegates that any
other plan be put in operation at this time. The American
Medical Association is now actively advocating the adoption in
every state of prepayment medical plans and is forming a new
organization of approved prepayment plans for the purpose of
exchange of information. Some members are proposing the
establishment of a national medically controlled prepayment in-
surance plan.

veterans’ administration

The Veterans Administration as you all know now is headed
by General Bradley with General Hawley as medical director.
Under General Hawley are Colonel Magnusson and Colonel
Harding. They are faced with a tremendous problem which
has two aspects: (1) To provide hospital and general medical
care to all veterans. (2) To make examinations to determine
pension ratings.

The Veterans’ Administration has requested the general med-
ical profession to assist them in taking care of the veterans, and
agreements are being sought with the state medical societies.
This committee recently met with Dr. Andreassen who is re-
gional director for the states of Minnesota, Wisconsin, Iowa,
North Dakota and South Dakota to discuss this problem. Dr.
Andreassen proposed that the North Dakota State Medical
Association sign an agreement with the Veterans’ Administra-
tion to furnish two types of medical service:

1. Care of the veteran locally for service connected disability
only. (It is to be noted that under present law, the Veterans’
Administration can only authorize care outside of the veterans
hospital for service connected disabilities. As much as possible
of this care will be given in the veterans own locality.)

2. Examination for pension rating. The Veterans’ Adminis-
tration wish to have most of these examinations done by the
general medical profession. The practitioner will be called upon
to furnish a complete report, including a report on all labora-
tory and X-ray examinations so that a reviewing body may
make a fair pension allotment on the basis of information fur-
nished. These examinations will be tedious and time consuming
as the forms must be properly executed.

3. Fee Schedule. The Medical Economics Committee has
approved a fee schedule that is in use in Minnesota, Kansas,
Michigan and other states for payment of services rendered to
the Veterans’ Administration. This is a fair schedule and we
feel that the doctor will be well repaid. It is our duty to make
every effort to give the best possible service under this program.
We must do a good job for the veteran and it will be one of
the best arguments against state medicine if we do so.

PROCEDURE

It is proposed that the Medical Association set up a central
office, probably in Bismarck, to handle all the administrative
details under this program. The Veterans Administration will

provide a veteran official connected with this office who will act
for them. The Veterans’ Administration offered to pay a per-
centage of possibly 7 per cent to 10 per cent of the total
amount of bills paid for the administrative cost of the organiza-
tion. This will be paid to the North Dakota State Medical
Association. At the time of writing this report, all details of
this plan are not completed. It is to be expected that a sup-
plementary report can be presented to the House of Delegates
and that the form of the program will be complete at that time.

W. A. Wright, M.D., Chairman
Dr. W. A. Wright, chairman of the Committee on Medical
Economics, added as a supplementary report a sample contract
of the agreement with the Veterans’ Administration and a fee
schedule for that program, both of which had been approved
by the Medical Economics Committee. A further supplemen-
tary report emphasizing the remarks of Donald Eagles of the
Blue Cross Organization was allowed and referred to the proper
reference committee. Mr. Eagles pointed out that the Cass
County Society put into effect a prepayment medical insurance
program effective March 4, 1946. He reported that enrollment
has already attained 10 per cent of the population of the city
of Fargo. He reported that the Blue Cross has enrolled nearly
one-half of the population in that town and was of the opinion
that the prepayment medical plan has the same opportunity.

REPORTS OF SPECIAL COMMITTEES

The following reports of special committees were referred
to reference committee on the report of the president, secretary
and special committees.

Industrial Health

Your Committee on Industrial Health did not hold an offi-
cial meeting during the past year and again the Annual Con-
gress, usually held in Chicago, was postponed.

A Regional Industrial Health Conference sponsored by the
Council on Industrial Health, American Medical Association,
will be held in Denver, Colo., on June 4, 1946. At the time
of this report (April 15) it is not known whether or not any
member of your Committee will be able to attend.

Your Committee approves of the aims and purposes of the
National Committee on Industrial Health and wishes to con-
tinue to cooperate with them in every way.

The small number of industries in North Dakota naturally
limits the scope of this Committee.

C. J. Glaspel, M.D., Chairman
War Participation

There was little for this Committee to do during the past
year. The chairman continued his work as state chairman for
the Procurement and Assignment Service for Physicians until
April 1, when the office was closed.

The medical profession in North Dakota established an en-
viable record during World War II. It met the demands of
the armed forces for medical officers without difficulty. Those
who remained at home carried on in spite of the shortage of
physicians in the state, and the increased demands for medical
service imposed upon them by a prosperous citizenry.

The medical manpower situation in North Dakota remains
serious. There are indications that the majority of North Da-
kota physicians who entered military service have returned, or
will return, to the state to practice. Their number, however,
will not compensate for the large number of physicians who
have been removed from active practice because of death, dis-
ability, age, or removal from the state. It is imperative that
our Association continues its efforts to encourage young physi-
cians to locate in the state.

The Committee on War Participation has completed its
work, and should be discontinued. The Board of Trustees of
the American Medical Association has recommended, through
its Committee on National Emergency Medical Service, that
a similar committee be appointed by each state medical associa-
tion. The Board also recommends that the majority of this
committee shall include civilian physicians who served during
the war. The state committee will cooperate with the A.M.A.
Committee on National Emergency Medical Service.

L. W. Larson, M.D., Chairman
Report of the Delegate to the American
Medical Association

Dr. A. P. Nachtwey, delegate, submitted the following report
which was referred to the reference committee on reports of the

September, 1946

301

council, councillors, and delegate to the American Medical
Association.

Your delegate begs leave to submit the following report of
the House of Delegates of the American Medical Association
held at Chicago December 3-5, 1945.

The A.M.A. House of Delegates has at the 1945 Session
formulated a positive, aggressive policy towards the future posi-
tion of medicine.

The House of Delegates instructed the Board of Trustees
and the Council on Medical Service and Public Relations to
develop immediately "a specific National Health Program, with
emphasis upon the nation-wide organization of locally-adminis-
tered prepayment plans.” This passed the House without a
dissenting vote.

The 1945 Session of the House was told that the Board of
Trustees is to engage an expert consultant to examine the entire
field of public relations of the medical fraternity.

An unusually large number of resolutions, numbering more
than 40, were presented to the House for action. Among the
most notable of these resolutions was:

Condemning the Compulsory Health "Sickness’ pro-
vision of the newest Wagner bill, because (1) The bill
is "predicated on the false assumption” that solution
of the medical care problem "is a panacea for all the
troubles of the needy”; (2) This is the first step in
a plan for general socialization not only of the medical
profession, but of all profession, industry, business and
labor; (3) Experience in other countries proves that
"Inferior medical service results from compulsory
health insurance”; (4) The program "enormously ex-
pensive,” would increase taxes for the entire popula-
tion, and (5) Voluntary prepayment plans, now spon-
sored by the profession in twenty-four states will ac-
complish all the objectives of this bill with far less ex-
pense to the people and will provide the highest type
of medical service without regimentation. It is further
urged that Congress delay action on anything like the
Wagner Bill until physicians in the armed services
have been released. They further instructed the Board
of Trustees and the Council on Medical Service and
Public Relations to prepare a warning to the Ameri-
can people regarding state medicine.

The House requested and endorsed a proposal that a perma-
nent conference on Medical Care be created with the American
Medical Association and government agencies represented.

A previous policy that the benefits under the Veterans Ad-
ministration be restricted to service-connected disabilities was
reaffirmed.

For the first time in the history of the A.M.A. a Section on
General Practice in the Scientific Assembly was established.

It was agreed that two sessions of the House of Delegates
were to be held annually.

A resolution advocating that licenses be offered in all states
to returning medical officers who are graduates of approved
schools was disapproved, holding that licensing is a matter for
individual states to regulate.

Harrison H. Shoulders of Nashville, Tenn., former speaker
of the House, was chosen president-elect and will be installed
in San Francisco, July 1, 1946.

The House adjourned, sine die, at 5:30 P.M. on December
5, 1945.

A. P. Nachtwey, M.D.

The Medical Center Advisory Council

A report of the representative of the North Dakota State
Medical Association on the activities of the Medical Center
Advisory Council to April 1, 1946.

To the House of Delegates, North Dakota State Medical
Association, in annual meeting in Bismarck, North Dakota,
May, 1946.

As your elected representative to the Medical Center Ad-
visory Council for a three year term at the business sessions of
the House of Delegates in Valley City in May, 1945, I sub-
mit herewith my report on the activities of the Council:

The organization meeting was held in Grand Forks in
August, 1945, upon call of the secretary, H. E. French, M.D.,
dean of the Medical School, University of North Dakota.
Governor Fred G. Aandahl had appointed Mr. W. W. Mur-
rey, Fargo, as a representative of labor, Mr. J. D. O’Keeffe,

Lansford, as a representative of agriculture and Mr. John A.
Page, Grand Forks, as a representative of the public at large
to the Council. These gentlemen, together with the following,
comprise the Council: Mr. Burton Wilcox, Center, North

Dakota State Welfare Board; Mr. Fred Traynor, Devils Lake,
Board of Higher Education; Mr. Mark I. Forkner, Bismarck,
Board of Administration; George F. Campana, M.D., State
Health Department; Mr. O. H. Overland, Grand Forks, North
Dakota State Hospital Association, and John H. Moore, M.D.,
North Dakota State Medical Association. All members were
present except Mr. Burton Wilcox, who was out of the state
at the time. Mr. W. W. Murrey was elected president and
Mr. J. D. O’Keeffe was elected vice president for terms that
will expire in June, 1946.

The balance of the day-long session was devoted to an in-
formal discussion of the many problems involved in operating
a medical center and the consensus was that such a center
would be of inestimable value to the people of North Dakota.

The second meeting of the Council was held at 10 A M.
on Tuesday, January 22, 1946, at the University of North
Dakota with Mr. W. W. Murrey presiding. Those present
were: Mr. W. W. Murrey, Mr. J. D. O’Keeffe, George F.
Campana, M.D., Mr. Burton Wilcox, Mr. O. H. Overland,
Mr. Lars Frederickson, Mr. C. H. Sherman, Dean H. E.
French, Mr. John A. Page, and John H. Moore, M.D.

The following motions were introduced and carried uani-
mously:

1. The Medical Center Advisory Council recommends to
each of the cooperating agencies that such agencies go on rec-
ord as favoring the establishment of a four-year (or complete)
medical course at the University of North Dakota.

2. The Medical Center Advisory Council recommends that
the University of North Dakota proceed at once to procure
plans for the construction of the science building (approved by
the 1945 North Dakota Legislative Session with an appropria-
tion of $250,000.00) to house the medical school and that the
expansion of the school be kept in mind during the planning
and construction.

3. The Medical Center Advisory Council recommends that
the University invite Dr. Victor Johnson of the American Med-
ical Association and Dr. Fred C. Zaffe of the American Asso-
ciation of Medical Colleges to the University for the purpose of
making inspections and giving advice.

4. The Medical Center Advisory Council recommends that
the Medical Center establish a teaching hospital with a mini-
mum of 200 beds on the University of North Dakota campus.

5. The Medical Center Advisory Council recommends that
the North Dakota State Medical Center employ a Director of
the Medical Center. It is further recommended that the di-
rector gather information for the next legislative session; seek
to obtain surplus government property; seek to raise funds;
investigate building costs, including the proposed medical build-
ing and such hospital that will be constructed in connection
with the Medical Center; and to use his efforts to investigate
every phase of the Medical Center development, including a
program of educational publicity. The Medical Center Advis-
ory Council further recommends that the Medical Center con-
sider the advisability of employing a professional money raiser
to solicit funds on a nation-wide basis.

6. The Medical Center Advisory Council recommends that
the cooperating agencies make available their facilities for the
development and expansion of the Medical Center as follows:
(1) Offer their technical staffs to assist and be associated with
the Medical Center. (2) Use the Medical Center Staff in the
different institutions in the promotion of a better and more
unified health program. (3) Open their institutions to the
Medical Center staff for observation and teaching.

After discussing in detail some administrative matters with
the president of the University of North Dakota, Dr. John C.
West, the Council recommended the appointment of Mr. John
A. Page as director of the Medical Center.

Subsequent to this meeting, Mr. Page accepted the appoint-
ment as director of the Medical Center and has established his
office at the University of North Dakota.

I recommend that the House of Delegates approve the mo-
tions as passed by the Medical Center Advisory Council at its
meeting on January 22, 1946. In the case of Motion 1, the
establishment of a four-year (or complete) medical course at

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the University of North Dakota, this was done by the House
of Delegates at the May 1945 meeting in Valley City.

Motion 4 and Motion 6 are particularly important to the
medical profession of North Dakota and a brief amplification
of them is indicated.

The Medical Center, while it is somewhat similar to the
Iowa plan in general form, differs radically from the Iowa plan
in the matter of centralization. The North Dakota plan is one
of decentralization. A teaching hospital of 200 beds is ob-
viously necessary for the teaching of undergraduates in medi-
cine. It is to be a hospital for the acutely ill patient. It is not
contemplated that patients are to be transported across the
state by ambulance to the University Hospital. It will draw its
patients largely from the area adjacent to the University but
indigent patients may be admitted to it on proper reference by
their local physician or by a proper certifying agency.

Motion 6 goes still further in the matter of decentralization
and is the heart of the North Dakota plan. In paragraph 1
of that motion, it if requited that the technical staffs referred
to shall actually be members of the University of North Da-
kota Medical School Faculty. This applies not only to State
Institutions such as the State Hospital at Jamestown, the Tu-
berculosis Sanatorium at Dunseith, the School for the Deaf
at Devils Lake, the School for the mentally deficient at Grafton
and the School for the Blind at Bathgate, but to the larger
organized private hospitals throughout the state whose staffs
would be willing to teach clinical medicine to undergraduate
students by means of clinical clerkships in residence at those
several institutions. Here is an opportunity for the private
practitioner to gain an intimate knowledge of the teaching of
modern medicine and for the student to learn the practical
problems of medical practice by the one most competent to
teach him, the private practitioner of medicine. In its essentials
it is a return to the Preceptor Plan of teaching, used so suc-
cessfully in the large medical schools in their small-section type
-r clinical teaching.

Paragraph 2 under Motion 6 suggests a way in which a
health program for the people of North Dakota can be worked
out under the guidance of the medical profession. A recent
report, emanating from the Governor's Postwar Planning Com-
mittee for Health, indicated that some 46 small hospitals were
requested to date. We, of the medical profession, know that
even if those hospitals were built it would be difficult, if not
impossible, to find competent doctors to man them. The Med-
ical Center Advisory Council believes that its decentralization
plan, based on a knowledge of local or area needs is more eco-
nomical and efficient from a health standpoint than the indis-
criminate building of hospitals. By "Medical Center Staff” is
meant those individuals who are actively engaged in teaching
in the School of Medicine, part time or full time, and whether
located at the University or living at the various contemplated
bases throughout the state.

Paragraph 3 of Motion 6 applies particularly to State Insti-
tutions as listed above. The working out of details "for obser-
vation and teaching” would obviously be administrative matters
for the heads of those various institutions to determine.

John H. Moore, M.D.

NEW BUSINESS
Recommendations of the Council

The Council recommended that Chapter 9 of the By-Laws be
amended and a new section 6 be added to read "that the dues
for non-resident members and former resident members who
continue to live in the state but who have retired from active
practice, pay dues of $10.00 per year.” In accordance with par-
liamentary procedure requiring recommendation to be in written
form and laid on the table for action during the second session,
this recommendation was tabled. The Council by the form of a
resolution recommended that returned service men who were
members of the association prior to entering the service receive
an adjustment on their dues to the extent that one who prac-
tices in the state for six months or less of the year shall pay
one-half of the annual dues and one who practices more than
six months during that year shall pay the full dues. This rec-
ommendation was referred to the Committee on Resolutions.

Dr. Larson read a letter which he had received on May 25,
1946, from the President of the North Dakota State Nurses
Association requesting the House of Delegates to approve a

proposed bill for an act to provide for the licensing and regu-
lation of practical nurses, providing for training of practical
nurses and prescribing penalties for violation thereof which the
State Nurses Association expects to introduce at the next session
of the state legislature. This letter was referred to the Com-
mittee on Resolutions.

Secretary Larson reported the status of the Hospital Licens-
ing Bill which is under consideration of the Subcommittee on
Hospitals of the Governor’s State Health Planning Board. He
reports that at this time the bill has been referred to the Attor-
ney General in an attempt to determine the possibility of some
legal implications involving conflict in the proposed bill with
existing statutes. Until these matters have been settled there is
nothing further to be done in connection with this bill.

Nominating Committee

The Speaker announced that President Hanna had appointed
the following to the Nominating Committee: Dr. O. A. Sed-
lak, chairman; Dr. A. P. Nachtwey and Dr. D. J. Halliday.
Adjournment

The First Session of the House of Delegates was adjourned
to reconvene at 8:00 P.M. on the same day on motion made by
Dr. P. H. Woutat, seconded by Dr. Waldschmidt and carried.

SECOND SESSION OF THE HOUSE OF
DELEGATES

Sunday Evening, May 26, 1946
The second session of the House of Delegates was called to
order by the speaker, John Moore, at 8:30 P.M. in the Rose
Room of the Patterson Hotel, Bismarck, North Dakota, May
26, 1946. The secretary called the roll. Sixteen delegates re-
sponded and the speaker declared a quorum present. The fol-
lowing delegates responded: Drs. V. G. Borland, Fargo; O. A.
Sedlak, Fargo; G. W. Toomey, Devils Lake; P. H. Woutat,
Grand Forks; L. H. Landry, Grand Forks; W. A. Wright,
Williston; A. R. Sorenson, Minot; D. J. Halliday, Kenmare;
A. H. Reiswig, Wahpeton; Paul T. Cook, Valley City; C. C.
Smith, Mandan; R. H. Waldschmidt, Bismarck; A. P. Nacht-
wey, Dickinson; W. W. Wood, Jamestown; M. J. Moore, New
Rockford; O. A. Knutson, Buxton.

The secretary read the minutes of the first session which were
approved as read.

Election of Officers

Dr. O. A. Sedlak, chairman of the nominating committee,
presented the following report. The speaker called for nomina-
tions from the floor. Hearing none he declared that a motion
would be in order to declare the nominees presented by the
nominating committee duly elected to their respective offices. Dr.
Woutat moved that the nominees be elected unanimously, sec-
onded by Dr. Waldschmidt and carried unanimously.

Doctors: A. E. Spear, president

Philip G. Arzt, president-elect
W. A. Liebeler, first vice president
W. A. Wright, second vice president
W. W. Wood, treasurer
A. P. Nachtwey, delegate to A.M.A., 1947
W. G. Toomey, alternate delegate to A.M.A., 1947
J. C. Fawcett, councillor, second district
Joseph Sorkness, councillor, seventh district
F. W. Fergusson, councillor, eighth district
A. R. Gilsdorf, councillor, tenth district
State Board of Medical Examiners (term three years): Drs.
D. J. Halliday, Joseph Sorkness, and George Williamson.

Selection of 1946 Meeting Place
The secretary announced that a formal invitation had not
been received. Dr. A. R. Sorenson stated "I would like to ask
the convention to meet in Minot next year.” Dr. Woutat
moved the acceptance of the invitation from Minot which was
seconded and carried unanimously.

REPORTS OF REFERENCE COMMITTEES
Reference Committee to Consider the Reports of the
President, Secretary and Special Committees
Dr. A. P. Nachtwey, chairman, presented the following re-
port which was adopted section by section and as a whole.

1. Report of the president: The report showed the multitude
of activities that are now forced upon the officers of the asso-
ciation. It has been made particularly apparent that the presi-
dent has faithfully fulfilled his obligation. Among the activi-

September, 1946

303

tics now incumbent upon a president of this organization is the
fact that it is necessary for him to meet with numerous pro-
fessional groups and to carry the message that the medical
association has to give to lay people. The committee reports
that this has been done in an exemplary fashion by your presi-
dent and that he has set a very high goal for his successor.

2. Report of the secretary: The report of the secretary is
as usual complete and edifying. The amount of work that the
society has seen fit to place on this man is most impressive. All
this work has been done in a most admirable fashion. We
wish to indorse the secretary’s recommendation that the Asso-
ciation continue financial support of the North Central Medical
Conference and we would further indorse the recommendation
that the president-elect and the vice president be utilized more
in the future than they have in the past.

3. Report of the committee on war participation: The opin-
ion of this committee that inasmuch as the work of the com-
mittee is accomplished that it be suspended is endorsed by your
reference committee. It was further recommended that a simi-
lar committee be appointed, this committee to cooperate with
the American Medical Association Committee on National
Emergency Medical Service.

A. P. Nachtwey, M.D.

A. O. Sedlak, M.D.

Paul T. Cook, M.D.

Reference Committee on Reports of the Council,
Councillors and Delegate to the A.M.A.

Dr. D. J. Halliday, chairman, presented the following report
which was adopted section by section and as a whole:

1. Report of the chairman of the council: The reference

committee recommends the adoption of the report of the council
and further recommends the adoption of a supplementary re-
port of the council regarding dues for returning servicemen.

2. Reports of the councillors. The reports of the various
councillors were assembled and we recommend that they be
adopted. We notice that some societies have held few meetings
during the past year due to stress of wartime conditions. We
recommend that these societies resume regular meetings as
soon as possible.

3. Report of the delegate to the American Medical Associa-
tion: Your reference committee has studied the report of the
delegate to the American Medical Association. We recommend
the adoption of this report. We call your attention especially
to the approval of the House of Delegates of the American
Medical Association of the voluntary, locally administered, pre-
payment medical care plans and to the fact that the American
Medical Association is urging that individual state or district
societies develop such plans.

4. Report of the State Medical Association representative on
the Medical Center Advisory Council. The reference committee
recommends that this report be adopted and that the action
of the Medical Center Advisory Council be approved.

Reference Committee to Consider the Reports of
Standing Committees

Dr. C. C. Smith, chairman, presented the following report
which was adopted section by section and as a whole.

1. Committee on medical education. We recommend the
adoption of this report of the committee on medical education
and wish to commend Dr. French and his committee for their
untiring effort to establish a medical center and a four year
course in medicine at the University of North Dakota.

2. Committee on Necrology and Medical History. Your ref-
erence committee recommends the adoption of this report. We
wish to commend Dr. Williamson and Dr. Wicks for the splen-
did manner in which they have assembled the information re-
garding our respected colleagues who have passed on since the
last meeting. The speaker of the House of Delegates then re-
quested all present to rise with the delegates for a moment
of silence in tribute to the members who had passed on (mem-
bers of the house of delegates and visitors stood one moment
in silent tribute) .

3. Committee of public policy and legislation. Your refer-
ence committee recommends the adoption of the report of the
committee on public policy and legislation.

4. Committee on public health. Your reference committee

recommends the adoption of the report of the committee on
public health with the following exceptions: (1) That para-

graph 5 be referred to the committee on public policy and

legislation. (2) That paragraphs 6 and 8 be referred to the
committee on venereal disease. We wish to commend Dr. Cam-
pana and his committee for the excellent work they have done
throughout the year.

5. Committee on official publication. Your reference com-
mittee recommends the adoption of the report of the committee
on official publication.

6. Committee on tuberculosis. Your reference committee rec-
ommends the adoption of the report of the committee on tuber-
culosis.

7. Committee on cancer. Your reference committee recom-
mends the adoption of the report of the committee on cancer
and wishes to commend Dr. Larson and his committee for the
interest and excellent work involving the cancer problem. We
also want to emphasize the necessity of approving the recom-
mendations of this committee.

8. Committee on fractures. Your reference committee rec-
ommends the adoption of the report of the committee on frac-
tures.

9. Committee on maternal and child welfare. Your reference
committee recommends the adoption of the report of the com-
mittee on maternal and child welfare. We wish to commend
this committee on the excellent work they have done.

10. Committee on crippled children. Your reference com-
mittee recommends the adoption of the report of the committee
on crippled children.

11. Committee on pneumonia control. Your reference com-
mittee recommends the adoption of the report of the committee
on pneumonia control and wishes to congratulate this committee
on the excellent work they have done.

C. C. Smith, M.D.

M. J. Moore, M.D.

A. H. Reiswig, M.D.

Reference Committee Report of Committee
on Medical Economics

Dr. V. G. Borland, chairman, presented the following report
which was adopted section by section and as a whole.

The committee on medical economics is to be commended
and thanked for their work during the past year, particularly
the efforts of their chairman, Dr. W. A. Wright. The refer-
ence committee recommends the adoption of the report on med-
ical economics.

The reference committee also recommends the adoption of
the supplemental report that was submitted by Dr. Wright to
the House of Delegates First Session, already approved by the
council, concerning the proposed plan including the contract
and fee schedule for the care of veterans in North Dakota.

V. G. Borland, M.D.

A. R. Sorenson, M.D.

R. H. Waldschmidt, M.D.

F. E. Wolfe, M.D.

W. W. Wood, M.D.

NEW BUSINESS

Dr. Sorenson reported that the American Academy of Pediat-
rics is attempting a survey of the states for facilities for the
care of children. Dr. R. E. Dyson of Minot, North Dakota,
has been appointed chairman for the committee in the state and
he is unable to be here. It was explained that Dr. Dyson
wished to get the reaction of the House of Delegates to this
proposed survey. Secretary Larson read excerpts from the in-
structions which had been submitted to Dr. Dyson which ex-
plained the purpose and scope of the survey. It was moved by
Dr. Sorenson that the physicians in the state cooperate in the
survey as requested by the American Academy of Pediatrics,
seconded by Dr. Landry (alternate delegate for Dr. Country-
man) and carried. It was explained by Dr. Hanna that the
Minnesota State Medical Association has completed a meeting
within the week May 21, 22 and 23. At that meeting the very
vital discussion on the problem of prepayment plan of medical
insurance was held. Dr. Adson, a member of that association,
was given the floor for a few remarks concerning this subject:

Dr. Adson explained that two plans had been under consid-
eration in Minnesota, there designated as being Plan A and
Plan B. Plan A is a voluntary doctors plan, while Plan B was
one underwritten by commercial insurance companies. He ex-
plained that the commercial companies definitely indicated their
interest in developing prepayment medical insurance in Minne-

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The Journal Lancet

sota and that the Blue Cross was of course opposed to their
participation and wanted to develop this field alone. The pro-
fession was circularized as to their desires and after a considera-
tion of the reports from these questionnaires and the remarks
of Dr. Will and several other past presidents, the council voted
15 to 6 for the doctor sponsored plan. The reference committee
reported the doctor sponsored plan back to the House of Dele-
gates with approval stipulating however that no further steps
be taken to carry out the plan until $100,000 has been fully
subscribed and paid. The reference committee also recommend-
ed cooperation with any commercial insurance company now
selling or proposing to sell prepaid medical insurance to the end
that the largest number of residents in Minnesota be provided
with some form of prepaid medical care in the shortest possible
time. Dr. Adson remarked that if the insurance companies do
drive us out of business we still feel that we have won because
we have accomplished the goal we set out to do, that is to ex-
tend the medical service on a prepayment or installment plan
as widely as possible.

Dr. W. A. Wright, chairman of the resolutions committee,
offered the following amendment to the By-Laws suggested by
the council: That a new section, section 6, be added to Chap-
ter Nine of the By-Laws, to read: "The annual Assessment for
Resident Members who have retired from the practice of medi-
cine, and of non-resident members, shall be $10.00 per capita,
unless otherwise ordered by the House of Delegates,” seconded
by Dr. Nachtwey and carried.

A further report was presented and adopted unanimously
as follows:

1. WHEREAS, the physicians of the Sixth District Med-
ical Society have contributed much to the success of the 1946
meeting of the House of Delegates,

BE IT THEREFORE RESOLVED, that a vote of thanks
be extended to the members of the Sixth District Society for
their contribution.

2. WHEREAS, the City of Bismarck and its Commerce
Association has provided comfortable, suitable and adequate
facilities for the 1946 meeting of the House of Delegates,

BE IT THEREFORE RESOLVED, that a vote of thanks
be extended to the City of Bismarck and the Bismarck Cham-
ber of Commerce for the courtesies extended and the facilities
provided.

Dr. Toomey, member of the committee on resolutions, re-
ported that the committee on resolutions to which the memor-
andum concerning a legislative plan for the North Dakota
Nurses Association concerning the licensing and regulation of
practical nurses was referred has studied the memorandum and
proposed legislative bill. It became apparent in the committee
discussions that this matter presents many different problems in
different sections of the state, hence requires considerable more
study than it is possible to give in the time at our disposal.
Accordingly the committee recommends that the incoming presi-
dent continue the Committee on Nursing Education and that
this matter be thoroughly studied by this committee in conjunc-
tion with our committee on legislation and public policy and the
appropriate committee from the North Dakota State Nurses
Association and other interested groups. Dr. Toomey moved
the adoption of this resolution as a continuation of the report
of the resolutions committee, seconded by Dr. Ferguson and
carried.

W. A. Wright, M.D.

O. A. Knutson, M.D.

G. W. Toomey, M.D.

Adjournment

The house of delegates adjourned sine die at 10:00 P.M.

SCIENTIFIC PROGRAM

Monday, May 27, 1946. City Auditorium.

9-12 A M. Registration. View Exhibits.

1—1:45 P.M. Scientific cinema, City Auditorium. Registra-
tion. View Exhibits, World War Memorial Building.

1:45—2:45. Early Diagnosis of Brain Tumors — A. W. Ad-
son, Department of Neurosurgery, Mayo Clinic, Rochester.

2:45-3:15. Obstetrical Emergencies — M. Edward Davis, Ob-
stetrician and Gynecologist to Chicago Lying-in Hospital; At-
tending Gynecologist to the Albert Merritt Billings Hospital,
Chicago; Professor of Obstetrics and Gynecology, University
of Chicago.

3:15-3:45. Intermission. View Exhibits.

3:45-4. Menopausal Bleeding — M. Edward Davis.

4-4:30. Intermission. View Exhibits.

4:30-5:30. Early Diagnosis of Cancer — Leo G. Rigler, Pro-
fessor of Radiology, University of Minnesota Medical School,
Minneapolis.

Announcements.

SPECIAL EVENING SESSION

8:00 P.M. City Auditorium. Medical Economics — Alfred
W. Adson, Member of the Council on Medical Service and
Public Relations, American Medical Association.

Tuesday, May 28. City Auditorium.

8:30-9 A.M. Movies at Bismarck City Auditorium.

9-9:30. Blood Plasma Program in North Dakota — Melvin
Koons, Director, Department of Laboratories, State Health
Department, Grand Forks.

9:30-9:45. Vocational Rehabilitation in North Dakota — A.
C. Fortney, Fargo.

9:45-10:30. Ocular Injuries — Hugo L. Bair, Mayo Clinic,
Rochester, Minn.

10:30-11. Intermission. View Exhibits.

11-11:45. Choice of Anesthesia in General Surgical Practice
— Ralph T. Knight, Director of Division of Anesthesiology,
Department of Surgery, University of Minnesota Medical
School, Minneapolis, Minn.

11:45-12:45. Common Dermatologic Diseases — M. G. Fred-
ricks, Duluth Clinic, Duluth, Minn.

2-2:30. Presidential Address — J. F. Hanna, President, North
Dakota State Medical Association, Fargo.

2:30-2:45. Inauguration of Incoming President.

2:45-3:30. Medical Program of the Veterans’ Administra-
tion— Einar C. Andreassen, Assistant Medical Director, Vet-
erans’ Administration, Minneapolis, Minn.

Installation of President

Dr. Hanna: It is with a great deal of pleasure that I ap-
point an honorary escort to accompany Dr. Spear, the Incoming
President, to the platform. Dr. Rodgers from Dickinson, and
Dr. Long, who is one of our past presidents and formerly of
Dickinson, will please accompany Dr. Spear to the stage. (Dr.
Rodgers and Dr. Long escorted Dr. Spear to the platform.)

Dr. Hanna: Dr. Spear, it is certainly a great honor and

gives me happiness to congratulate you. I am certainly happy
to turn over to you an Association that is waiting for leader-
ship; a House of Delegates and a Council that are always will-
ing to serve you. I wish you the best of luck. If there is any-
thing I can do to assist you, I will be only too happy to have
you call upon me.

Dr. Spear: Mr. President, Members of the Board of Di-
rectors, and Council, Members of the Association and Visitors:

Words cannot express my appreciation for the honor and
privilege of serving you for the ensuing year. It is especially
pleasant to be thus remembered at a time when I should expect
to be forgotten. I will do my best, but don’t expect too much!
My only policy will be to carry out your wishes, and that we
may have a successful year, I ask your confidence and co-
operation.

In behalf of the Members of the North Dakota Medical
Association, I wish at this time to express our appreciation and
thanks to the officers and committees who have done such a
good job during the past year.

The President, Doctor Hanna, has faithfully and diligently
performed more than his duty.

The Speaker, Doctor Moore, and the House of Delegates,
have done a wonderful job in handling many complex and
difficult problems. They are a grand and capable group of men
under a capable speaker.

The Council and its Chairman deserve the highest praise for
managing the business affairs of the Association.

All the committees have done fine work. I want especially
to commend the work of the Committee on Medical Economics
under their Chairman, Dr. W. A. Wright. Dr. Wright has
given freely of his time and effort. He has had a difficult job
and has done it with commendable success.

There is one man who, I believe, above all others, has con-
tributed to the progress of our Association. Men are measured
by what they accomplish; the contribution they make to prog-
ress and development. Our Secretary, Dr. L. W. Larson, with

September, 1946

305

great sacrifice to himself, and in addition to his regular duties
has given of his time, his best efforts, and his great ability,
in the interests of our Association. Every member of the Asso-
ciation is deeply indebted to Dr. Larson for the service he has
rendered, and I suggest that we all give him a hand.

The response of the members of the Association to the in-
crease in dues has been very gratifying. It shows that the mem-
bers are conscious of the need for the organization and appre-
ciate its activities. The employment of a full-time Secretary
will allow the scope of these activities to be even more exten-
sive and beneficial.

I wish to extend to the doctors who have returned from the
Services a hearty welcome. We have missed you sorely, both
professionally and personally. There are many fine locations in
the state open to each of you. Doctors returning from the
Service present no problem in our Association; the only prob-
lem is to get them back fast enough.

I was very much interested in reading the recent report of the
Hospital Sub-Committee of the North Dakota State Health
Planning Board. All too often the work of investigating com-
mittees consists first of magnifying some condition until it be-
comes an emergency, or even creating an emergency, then rec-
ommending appointment of another committee or bureau to
take care of this emergncy.

But this committee has an entirely different attitude. They
first made an extensive survey of the Medical Care and Health
Facilities of the state. They then drew up a plan for a "Hos-
pital Program” for the whole state. They do not propose any
far-fetched plan involving a hospital at every crossroad, or even
in every village or hamlet. Their plan urges the consideration
of hospital needs on an area basis instead of a community basis.
It also provides for "base” hospitals as centers for the most
highly specialized medical services, and the training of medical
personnel. Under this plan the larger hospitals of the state
would be designated "regional” hospitals where practically all
types of specialist care would be available; and the smaller hos-
pitals, designated as "district” hospitals, not so highly special-
ized. Patients at "district” hospitals, found to be in need of
services not available, would be referred to a "regional” or
"base” hospital.

Under the plan it would be necessary that the two-year med-
ical course at the University be extended to a four-year course.

The report shows sincere effort and constructive work, and
is well worth reading.

Plans for changing the medical course at the University from
two to four years are progressing. This plan would work in
nicely with the plans for one or more "base” hospitals of the
Health Planning Board. I believe it would also eventually help
solve the problem of shortage of doctors in the state. The plan,
I believe, deserves our support.

The plan for care of veterans, between the V.A. and this
Association seems very fair. This job fell to Dr. Wright’s Eco-
nomics Committee and as usual was well handled. The fees are
reasonable, and the paper work has been reduced to a minimum.
I think it should be acceptable to all.

The monster, "Socialized Medicine,” again rears its ugly
head as S. B. 1606. This Bill — you are all familiar with it—
provides for compulsory prepaid federally controlled medical
insurance and is socialized medicine at its worst, claims of the
President and Mr. Murray to the contrary notwithstanding.
Of course, this is only one feature of the Bill, which proposes
to furnish complete "Social Security” for millions of people
on a compulsory fee payment plan. There is nothing new in
this "Social Security” idea. It has been tried many times by
many countries with disastrous results. In our own country it
existed up to 1863 under its right name, "Slavery”. The peo-

ple involved, or covered, enjoyed all the advantages of the pres-
ent proposed plan. They were completely protected from "cradle
to grave,” but at the cost of their freedom. Any compulsory
Social Security plan today will deprive those covered of their
freedom and liberty as American citizens. We believe that
there is no such thing as social security except in the grave
or as slaves.

I believe that we, in our deep and justifiable concern for the
future of the science and practice of medicine, have neglected
to consider sufficiently the best good of our patients, the gen-
eral public. In our consideration of this subject we must forget
our personal preference and advantage, for it must eventually
be solved in the interest of the patient. If the Government can
take better care of the patients than the doctors can, we should
not oppose the plan or we could be rightly accused of promot-
ing our personal interest to the detriment of the public.

Anyway, whatever system is good for the patient should also
be good for the doctor, but we do not believe "Socialized Medi-
cine” is to the best interest of either. It would most certainly
mean loss of freedom and the constitutional right of liberty for
both. It would result in poorer medical care for the patient
and regimentation of both patient and doctor. The immense
overhead expense of bureaus, committees, and personnel for ad-
ministration would be appalling and would but result in a much
bigger and better "pork barrel”; yet this dangerous plan is be-
ing vigorously championed by many intelligent and sincere, if
misinformed and misguided people. It is also being championed
by many for their own individual or political advantage.

The challenge is here — what are we going to do about it?
We will accomplish nothing by merely picking flaws in the pro-
posed system. The situation demands constructive thinking
and acting.

It is not enough to defend the principles of private practice
and the confidential relationship of patient and physician.

The public should be informed as to the dangers of federally
controlled medicine. Nothing is "given” to the public or indi-
vidual by the Government but what much more is demanded
in return. The price of Social Security is too high, for it
means the loss of our liberty, freedom of personal effort and
individual advancement.

President Dodds of Princeton wrote, "Concentration upon
security as a goal is suicidal. When we make the mistake of
placing our hope in measures of Security rather than in willing-
ness to venture toward larger growth, decay has begun.” And
Dr. Louis Karnosh says, "Man cannot have security and free-
dom at the same time.”

The goal of American medicine should be such a distribution
of medical service that no patient in these United States need
ever lack the best possible care at a price he can afford to pay.
American medicine has come a long way toward this goal dur-
ing the past few years. Blue Cross Plan for prepaid hospital
service now has over 20 million members. Prepaid medical
service plans are now in use in fifteen states. Dr. J. E. Mc-
Cormick, chairman of the A.M.A. Council on Medical Service
and Public Relations, says, "Within a year there will be at least
forty state-wide medical society sponsored plans in operation.”
The Council is also prepared to establish an interim national
casualty company that will offer coverage where no other plan
exists.

In view of the progress that has already been made and the
high type of leadership which we have, I am confident that
American medicine will be able to meet the challenge and
solve the problem to the best interest of both the public and
the profession without the evils of compulsion or federal regi-
mentation.

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The Journal Lancet

Presidential Address

J. F. Hanna, M.D.

Fargo, North Dakota

The honor conferred upon me a year ago of being
elected President of the North Dakota State Medical
Association is an honor deeply appreciated. There have
been many fine men and able leaders in medicine and
community welfare who have preceded me in this office.
To join their ranks is indeed an honor.

I am most happy to welcome you back to a peace-
time State Medical Meeting. We are all happy to wel-
come back to civilian practice the members of this So-
ciety who had joined the colors. Their service to their
country and their aid to our young boys and girls in
their hour of need, have built a proud heritage for the
North Dakota State Medical Society. They gave ' of
themselves, of their time, and of their financial oppor-
tunity. For us and for the nation as a whole this is a
sacrifice which cannot be repaid. Let us not forget their
sacrifice and make our words their only reward. Words
are easy. If the opportunity should arise to show our
appreciation, let us make it a working principle that all
other things being equal, the doctor veteran shall come
first. Let us make their readjustment to civilian prac-
tice less difficult.

As one looks backward over a year’s time, it is seldom
that one can say, "I have done all and accomplished all
that I had planned.” My term of office has left unfin-
ished many of the objectives I had hoped to accomplish.
Not the least of these has been my inability to visit a
number of the local medical societies. As you know,
there is much to be discussed and many plans to be made
for the future of medicine. The focal point of interest
in the future of medicine is to be the County Medical
Society, large or small as it may be.

It is the voice of the County Society with its member-
ship of men actively engaged in the practice of medicine
and a part of the people in a county or legislative district
that must speak out. That is the voice that our national
and state legislative bodies wish to hear to help them
shape their actions accordingly. They have become too
familiar with the radio voices and press releases of or-
ganized medicine on a national level. The American
Medical Society knows this all too well.

No member of our legislative bodies will hesitate to
criticize the National Society, but will surely give serious
thought before attacking the Local Medical Society in
his own district. And so, realizing the importance of
the local unit, it is with extreme regret that, as State
President, I did not visit as many county societies as I
had desired.

I would like to suggest at this late date, if I may,
that each County Society’s Program Committee reserve
one meeting a year for a report to you of the proposals
and problems facing your State Society.

Since assuming the presidency, it has become very
apparent to me that state officers should take a more
active part in the affairs of the State Society. The vice
president and president-elect should start their appren-

ticeship upon election to office. They could arrange to
meet with the local societies in their nearby district.
In this, way, all the county societies could be visited by
their state officers. The local society would thus receive
state and national medical reports, and the state officer
in turn would become acquainted with the desires and
plans of the local county members. In this way, too,
a wide diversity of opinions might be discussed in a
friendly manner, and general benefits result to the state
profession as a whole. The attendance of such officers
at meetings of state and local health planning groups
would also be important and beneficial to all. The ex-
perience and knowledge gained would well prepare them
to carry on the duties of the state presidency. I have
too well discovered my lack of apprenticeship for the
presidency by assuming all its duties in one year.

As the war years closed in 1945, it is self-satisfying
to look back on the dangers that were met and overcome.
To look forward to the challenge of 1946, we see that
our resources will again be tested. The coming year will
be important in the field of medicine. It will require
careful planning, consistent work, and last but not least,
faith in our ultimate objectives.

We must face the fact that 1946 ushers in a period
of readjustment and new alignments. If we have nothing
to offer the future but the experience of the past, we
shall lose prestige as a directing force to the people of
the state. It is inevitable that we must show a willing-
ness to accept some change in methods, but let us be
determined to preserve the fundamentals of medical
practice that have given to this country and to the world,
the highest type of health protection to be found any-
where.

We see on all sides the striving for equitable adjust-
ments between industry and labor. We and all the other
professions share with industry and labor the same gen-
eral problems. Group leadership can help in leading us.
The medical profession is made up of small units with
the American Medical Association at the head. In the
main, the battle shall be fought, won or lost, in the small
units known as the County Medical Society.

As much as I would like to discuss with you a purely
medical subject, I feel that you should hear from me
in some small way regarding the Medical Social Eco-
nomic Situation in the state.

I would like to review with you some of the problems
facing the medical profession of North Dakota in the
postwar period. I have classified them under three
headings:

1. Equitable distribution of physicians.

2. Equitable distribution of medical facilities.

3. Equitable distribution of medical costs.

The first two subjects have been presented to us by
the findings of the North Dakota Health Planning
Committee. The third subject has received attention in
the social and economic efforts in past and present reso-

September, 1946

307

lutions and bills that have been introduced into Congress
dealing with the extension of the Social Security Pro-
gram for the provision of health insurance. The latest
effort in this regard has been the Wagner-Murray Bill
of November 1945, introduced into the Senate as S. B.
No. 1606.

One of the major problems facing the profession in
North Dakota is the equitable distribution of medical
care and medical facilities in some of the rural counties.
If one gives any thought or study to the national situa-
tion, it becomes very apparent that the greatest defi-
ciencies exist in the small villages and their adjacent
areas. Membership in the North Dakota State Society
during 1945 was 360 physicians, 57 of whom had joined
the Armed Services. The report of the North Dakota
State Health Planning Committee of March 1945 listed
335 effective physicians. The ideal ratio of one physi-
cian to 1500 patients exists in only four counties, repre-
senting 23 per cent of the population of the state.

War dislocation caused the physician-patient ratio in
about a third of all U. S. counties to drop to one physi-
cian for 3000 patients. The last twenty years has shown
a decline in the number of physicians in the rural areas
of North Dakota. Economic conditions have played a
major role in this change but other factors have com-
bined to this end, such as the improvement in state high-
ways, and the mass production of automobiles with the
decrease in cost, making ease of transportation available
to the large majority of our rural population. One
result has been the development of trade areas in the
state into economic, medical and educational centers.

The once self-sufficient small town or village has be-
come a passing point in the rural populations seeking
merchandise values or medical care.

A natural result has been the desertion on the part
of the rural populations of two important members of
their community, the doctor and the merchant. They
were both forced to move to centers of larger population.

The advances in medical science have stimulated the
development of medical specialties and increased the
need for conferences and consultations among physicians.

Medical education of today stresses the need of mod-
ern methods in diagnosis and treatment.

The rural population of today has also become med-
ically educated. They are not satisfied with other than
modern methods in diagnosis and treatment. Two dec-
ades ago, we had an adequate distribution of physicians
in rural areas. This can be explained on the basis that
medical knowledge was limited and all graduates were
on a fairly equal level as to training. To some, rural
practice offered the internship service of that time.

The medical graduate of today, however, is predom-
inantly from the urban centers. He affiliates for his in-
ternship and fellowship in a large urban hospital. Upon
completion of his hospital tour of duty, he wishes to
retain the contacts he has made and to practice under
the same ideal conditions. It is only natural that he
wishes to remain in the city.

Medical knowledge has advanced so rapidly during
the past few decades that it has become impossible for
an individual to keep pace with its progress in all

branches of medicine. This has caused the medical stu-
dents’ training to lead to specialization.

Medical educators should give thought to the prob-
lems resulting from over-specialization. If the large
urban hospitals would offer intern training pointing to
specialization in rural practice from six months to one
year, let us say, to be spent in an affiliated rural hospital,
the young doctor would obtain rural medical experience
and contacts in the rural area so vital to one starting his
practice. The country as a whole needs specialists in
rural training; specialists who are competent to meet an
emergency under unfavorable conditions, who have a
broad concept of disease and a sound sense of diagnosis
and therapy.

To offset the medical trend towards the cities, the sug-
gestion has been made that state universities offer tuition-
free medical courses to students who agree to practice a
specified time within a state in a designated community.

Organized farm groups strongly urge medical training
for worthy farm boys under a medical scholarship plan,
tuition free. This is the type of student who knows
rural life and who would be interested in returning to
the smaller towns to practice. Our state university offers
two years of pre-medicine and the first two years of the
regular four year medical course. It was with the thought
in mind of keeping our own boys in the state after grad-
uating in medicine that the medical center legislation
was passed in 1944. The medical care of the state de-
pends a great deal on the return of native sons and
daughters to North Dakota to practice. They know the
state, its people, and its medical needs.

Intimately related with the distribution of medical
personnel is the location and distribution of medical facil-
ities. The hospital has been rightly called the doctors’
"workshop”. To interest the medical graduate of today
in a community to practice, access to hospital facilities
is a major influence. If we hope to attract and hold
young men for practice in this state, facilities must be
given the young doctor to do satisfactory work for him-
self and for his patients.

In every state of the Union certain areas have de-
veloped that have neither sufficient medical personnel or
medical facilities. This need exists predominantly in
states where the majority of the population lives in rural
areas and presents the most challenging problems in the
whole field of hospital and medical care.

The hospital facilities of North Dakota maintain high
standards in numbers, location and quality of service.
The total number of hospitals in the state is 46 with
a bed capacity of 6,243. Of this number, 20 are ap-
proved by the American College of Surgeons, and 41
by the American Medical Society. The estimated civilian
population of the United States by counties as of No-
vember 1, 1943, by the Bureau of Census shows the
number of beds in approved and unapproved general
care hospitals in the state to be 4.9 to each 1000 popu-
lation. The ideal ratio is placed at 4.5 beds to each
1000 population.

Unfortunately, there are counties and communities in
the state that have no medical facilities. It is their hope
to attract doctors by building small hospitals to make

308

The Journal Lancet

medical practice more attractive in their locality. In
localities of this type, the greatest care must be exercised.

The history of hospital construction is that facilities
often have been built with no particular interest in com-
munity need. Misguided civic enthusiasm often results
in duplication and waste, the natural outgrowth of un-
guided expansion.

The coordinated hospital service existing between a
district hospital and a community center offers the best
solution to the problem of rural medical care. This co-
ordination of hospitals best exists in areas covered by a
radius up to 50 miles, the condition of roads and ease
of travel and transportation deciding the size of the area.

The district hospital would act as a diagnostic center
and would undertake the treatment of patients with
more involved illness. The community center with ten
beds and office space for doctors and dentist would care
for the more routine cases. The district hospital must
in no way take over functions or patients that could be
cared for in the smaller hospitals. This idea offers un-
limited possibilities.

The district hospital’s monthly staff meetings, the
weekly pathological conferences, and the grand rounds
of the surgical and medical staff all would be open to
the doctors practicing in the co-ordinated hospital area.
The problem of nursing care in the community center
could be improved by nursing affiliation with the district
hospital. This coordination could also exist between the
Board of Trustees and Superintendents, the community
center having the advantage of experienced management
and reduced buying costs.

The sound working relationship between the rural and
urban district hospital does away with size as a measure
of efficiency in the rural hospital or community center.
The quality of care for rural dwellers would approach,
or reach parity with, the urban dwellers. The fear and
danger of professional stagnation which dissuades young
physicians from taking up country practice would be
largely removed.

To some, the idea of hospital cooperation may sound
visionary and impractical. The idea of competition and
individualism has deep roots in our thinking, due to
past success. Hospital coordination is practical and bene-
ficial to the small hospital as well as the large. It is
practical because it has already proven so in one of our
oldest and most conservative states.

The last link in the triad of postwar medical plan-
ning is the equitable distribution of medical cost, making
medical care available to all classes of people. This
social-economic adjustment affecting the people and the
medical profession of the nation may well be one of the
great social changes of a generation.

To implement this noble ideal, two plans have been
suggested: (1) Compulsory insurance administered un-
der government control and financed by taxation. (2)
Voluntary insurance free of compulsion and financed by
the individual. The main contention of those in favor
of a government supervised plan is that it will help all
classes of people. All employed persons receiving $3,600
or less will be taxed 4 per cent of their yearly salaries
no matter how meager they be. Under the same system

of compulsion it will also make medical care available
to those with incomes above $3,600, to those with sal-
aries of $15,000 yearly, as well as to national celebrities
with salaries of $100,000 or more. These also shall
receive medical service for a tax of 4 per cent on their
incomes up to $3,600, amounting to $144 a year. This
is something new in Medical Economics, the poor pay-
ing for the rich. The great majority of the taxpayers
are those in the moderate to low income group and un-
der the plan they must help to pay the cost of medical
care for the high income group.

The cost of Federal Insurance has no actuarial basis
by which to estimate the cost to the nation. It is stated
the cost will be no more than medical payments under
our present voluntary regime. The estimated cost of
medical care in normal times amounts to over 2 billions,
($2,008,000,000). The Department of Labor in 1940
reported a cost of $59 annually for medical care to the
average American wage earner; of this amount $13 cov-
ered the physician’s charge.

The present estimated expense of Compulsory Per-
sonal Health Service is approximately 3 /i to 4 billion
dollars. This stupendous sum is to be supplemented by
appropriations from general revenue. This is an alarm-
ing figure in view of the heavy tax burden we now
carry.

Let us use as a yardstick one federal venture into
medical economics. The Emergency, Maternal and In-
fant Care Act was increased from an initial appropria-
tion of $1,200,000 to $42,800,000 in 1946, representing
a 41 million dollar increase in three years. This was for
a limited number of persons in the nation.

The self-employed, which includes farmers, will be
taxed 4 per cent of their income. Those with incomes
of $3,600 pay $180 annually or 50 cents a day. If one
or more of his family are employed on a full or part-
time basis, they would also be taxed. A premium of
$180 yearly is not inexpensive insurance.

The cost for medical service under government com-
pulsory insurance at a tax of 4 per cent on yearly in-
comes is exorbitant when compared to (some) voluntary
plans. Many persons under group insurance are insured
for $60 a year plus their dependents in home sickness,
accident, hospitalization and surgical service. The com-
bined voluntary plans of Blue Cross Hospitalization,
Physician Service, Co-operatives Health and Accident
and Mutual Medical service plans insure about 50 mil-
lion people. The greatest increase in membership has
been in the past five years with the physician service
plans producing the largest enrollment in the last two
years. Many voluntary insurance plans have doubled
their membership during *this time. It is true no one
is compelled to seek medical care under the compulsory
system of insurance, but he will be compelled to pay
taxes to support a system he may not believe in. This
is certainly a curtailment of freedom.

There are a great many people who wish to have med-
ical treatment but who do not see why government
should force them to save for it any more than it forces
them to save to buy better food, better clothing or better
housing, all of which are certainly essential to good

September, 1946

309

health. The veteran when employed will be taxed for
medical care that has been promised him free of any
cost in the G. I. "Bill of Rights,” the gift of an appre-
ciative nation.

According to conservative estimates, it would take at
least 600,000 additional salaried government employees
to administer the Compulsory Health Insurance Pro-
gram. The total number of effective physicians in the
United States is 160,000. For every physician there
would be about four bureaucrats. This army would draw
on an average of $3000 a year each, according to the
present average federal salary pay. To quote a liberal
of international fame, "The expenditure for ink will
exceed that for iodine.” The cost of this venture into
medical economics should not be considered if it is to
procure better medical care for the nation.

The medical facilities and medical personnel of this
nation stand second to none, and the highest health
standards and the lowest mortality rates are ours. Will
the people be satisfied with the health records of Eng-
land or Germany? Both nations are comparable to ours,
being highly industrial with a large rural population.
They have enjoyed the benefits of compulsory insurance,
Germany for nearly 60 years, and England for nearly
35 years.

Much has been made in this country of draft statis-
tics in the past three years. The rejection rate of those
called for induction into the U. S. Army was about
38 per cent for physical reasons. In the English Army,
where lower standards for induction prevail, the rate of
rejection was 50 per cent. This was after the English
Nation had the benefits of compulsory insurance for a
third of a century.

Again to cite the draft statistics, 280,000 were re-
jected for syphilis. The education of the public as to
the dangers of this disease and the availability of free
treatment to all has been carried on for years by the
U. S. Public Health Service. This group cannot be
used therefore by those that tell us "Inability to pay is
the only bar to good medical care.”

Will an increase in the rate of cardiac disease, cancer

and diabetes be acceptable to labor and certain farm or-
ganizations? That is the record under compulsion in
Germany and England when compared with the present
voluntary system of medical care offered by this nation.

Medical education is no longer centered in the univer-
sities and clinics of Europe. Graduates of foreign coun-
tries seeking advanced training now come to the univer-
sities and clinics of this country. Can this high standard
of medicine be continued under a system of compulsion?
Is it not possible that political medicine will rob the
young doctor of his competitive spirit, and his desire to
render the best in service?

There is one other factor in the situation which is disturbing
and should concern the citizens as well as the physician. That
is the spectre of the bureaucrat. Gradually in such a system,
there will emerge "The Man Behind the Desk,” the official
whose task it will be to see that the interests of government are
protected. It is this man whom a free medical profession fears.
His influence will filter down through the whole medical system.

Will the enactment of federal insurance give equitable med-
ical care to all those taxed for its support in that section of the
United States requiring the greatest amount of federal assist-
ance and with the highest morbidity or mortality rates? Anyone
familiar with the records of their representatives on a national
and state level has grave reasons for doubt. The protection and
exercise of a very fundamental, moral and constitutional right is
denied a large number of a class of citizens by the failure of their
representatives to support a Fair Employment Practices Act.

This rather lengthy discussion of state medical needs to which
the large majority of us agree in principle must be implemented
by action. If the medical profession in the state and the nation
as a whole does not act quickly to offer a workable plan that
will insure adequate medical care, coordinated hospital service,
and medical cost within the means of all, political medicine will
take over. We must plan for community welfare in both pre-
ventative and curative medicine. The democratic way is to meet
medical cost through a budget set up for illness through volun-
tary insurance by those able to do so. The less fortunate may
be aided by insurance contracts financed at state or county
levels. If we do not accept this challenge and refuse to give our
time to its support, we can well expect and rightly so, to face
the enactment of measures politically administered, followed by
the degradation of bureaucratic control. On the other hand, if
we act with united effort and zeal capable of the profession as a
whole, our efforts will convince the people of our honest desire
to lead them on the road to health. We shall then be able to
pass on to a future generation of doctors the proud heritage
we have enjoyed under a democratic system of medical practice.

NORTH DAKOTA STATE MEDICAL ASSOCIATION

ROSTER-1946

PRESIDENT

Borland, V. G. .... Fargo

SECRETARY-TREASURER
Heilman, Charles Fargo

Bacheller, S. C. Enderlin

Baillie, W. F. Fargo

Bond, John H. Fargo

Borland, V. G Fargo

Burt, A. C. Fargo

Burton, P. H. Fargo

Clark, I. D., Jr. Fargo

Clay, A. J. Fargo

Darner, C. B Fargo

Darrow, F. I. Fargo

Darrow, K. E. Fargo

DeCesare, F. A. Fargo

Dillard, J. R. Fargo

Elofson, Carl E. Fargo

Fjelde, J. H. .... Fargo

MEMBERSHIP BY DISTRICTS

CASS COUNTY MEDICAL SOCIETY

Fortin, H. J. Fargo

Fortney, A. C. Fargo

Foster, G. C. Fargo

Gronvold, F. O. Fargo

Hanna, J. F. Fargo

Haugrud, E. M. Fargo

Hawn, H. W. Fargo

Heilman, Charles O. Fargo

Hendrickson, G. Enderlin

Hunter, G. W. Fargo

Huntley, W. B. Kindred

Ivers, G. U. Fargo

Joistad, A. H. Fargo

Klein, A. L. Fargo

Lancaster, W. E. G. Fargo

Larson, G. A. Fargo

Lewis, T. H. . Fargo

Long, W. H. Fargo

Mazur, B. A. Fargo

Miller, H. W. ......

Casselton

Morris, A. C.

Fargo

Nichols, A. A.

Fargo

Nichols, W. O.

Fargo

Oftedal, Trygve ...

Fargo

Ostfield, J. R.

Fargo

Patterson, T. C. _.

Lisbon

Pray, L. G.

_ Fargo

Richter, E. H.

Hunter

Sedlak, O. A.

Fargo

Skelsey, A. W. ..

Fargo

Stafne, Wm. A. ...

Fargo

Stolinsky, A.

San Francisco

Swanson, J. C.

Fargo

Taintor, Rolfe

Fargo

Tronnes, Nels

.. Fargo

Urenn, B. N.

Fargo

Watson, E. M.

_ Fargo

Weible, Ralph D.

Fargo

310

The Journal Lancet

PRESIDENT

Palmer, D. W. Cando

SECRETARY-TREASURER

Fawcett, D. W. Devils Lake

dayman, Sidney .... San Haven

Engesather, J. A. D. . Brockett
Fawcett, D. W. Devils Lake

DEVILS LAKE MEDICAL SOCIETY

Fawcett, J. C. Devils Lake

Fawcett, N. W. Devils Lake

Graham, J. D. ... Devils Lake

Greengard, Milton .... Kolia

Horsman, A. T. Devils Lake

Hughes, B. J. Kolia

MacDonald, J. A. Cando

McKeague, D. H. Maddock

Palmer, Dolson W. .... Cando

Reed, Paul : Rolette

Ruud, John E. Devils Lake

Sihler, W. F. Devils Lake

Smith, Clinton Devils Lake

Stickelebrger, Josephine ... Oberon

Toomey, G. W. Devils Lake

Vigeland, J. G Brinsmade

GRAND FORKS DISTRICT MEDICAL SOCIETY

PRESIDENT

Dailey, C. W. Grand Forks

SECRETARY-TREASURER

Canterbury, E. A Grand Forks

Alger, L. G Grand Forks

Bartle, J. P. Langdon

Benson, T. Q. Grand Forks

Benwell, H. D. Grand Forks

Brown, Bernice E Grand Forks

Brown, G. F. Grand Forks

Burrows, F. N. Bathgate

Campbell, R. D. Grand Forks

Canterbury, E. A Grand Forks

Caveny, K. P. Langdon

Countryman, G. L. Grafton

Countryman, J. E. Arch Cape, Ore.

Dailey, Walter C. Grand Forks

Deason, Frank W Grafton

Field, A. B. Forest River

Flaten, A. N. Edinburg

French, H. E

Fritzell, K. E.

Glaspel, C. J.

. Grand Forks
. Grand Forks

Goehi. R. O.

. Grand Forks

Graham, Chas. M. ..

Griffin, V. M.

Grinnell, E. L.

Hardy, N. A. ...

Grand Forks
Grand Forks
Grand Forks

Haugen, C. O. . .

Hetherington, J. E.
Jensen, A. F.

.. Grand Forks
Grand Forks

Lamont, John G. . ..

Landry, L. H

Leigh, R. E.

Liebeler, W. A.

Lohrbauer, L. T. .

Lommen, C. E.

Mahowald, R. E.

Moore, John H.

Grafton

Walhalla

- Grand Forks
. Grand Forks
.. Grand Forks

Fordville

Grand Forks
Grand Forks

Muus, O. H.

Grand Forks

Panek, A. F Milton

Peake, Margaret F. ... Grand Forks

Quale, V. S. Grand Forks

Rand, C. C Grafton

Ruud, H. O. Grand Forks

Ruud, M. B. Grand Forks

Savre, M. T Northwood

Silverman, Louis Grand Forks

St. Clair, R. T Northwood

Thorgrimson, G. G. Grand Forks

Tompkins, C. R. Grafton

Vance, R. W. Grand Forks

Vollmer, Fred J Grand Forks

Waldren, G. R. Cavalier

Waldren, H. M., Jr Drayton

Weed, Frank E. Park River

Welch, W. F. Larimore

Williamson, G. M Grand Forks

Witherstine, W. H. ... Grand Forks

Woutat, P. H Grand Forks

Youngs, Nelson A Grand Forks

KOTANA DISTRICT MEDICAL SOCIETY

PRESIDENT

Korwin, J. J. Williston

SECRETARY-TREASURER

Johnson, A. K. Williston

AbPlanalp, L. S Williston

Craven, J. D. Williston Korwin, J. J.

Craven, J. P. Williston Lund, C. M.

Hagan, Edward J. Williston McPhail, C. O.

Johnson, A. K. Williston Skovholt, H. T.

Jones, Carlos S. Williston Wright, W. A.

NORTHWEST DISTRICT MEDICAL SOCIETY

PRESIDENT
Halverson, H. L.

Blatherwick, W. D.
Breslich, Paul J. ....
Call, A. M.

Cameron, A. L.

Carr, A. A.

Conroy, Martin P.

Craise, O. S. ....

Cronin, Donald J.
Devine, J. L., Jr. ..
Devine, J. L., Sr.
Downing, W. M. .

Erenfeld, F. R.

rvfinot

Fischer, V. J.

Flath, M. G.

Minot

... . .. Stanley

RER

Minot

Fox, W. R. ...
Fulton, A. M.

Rugby

Minot

Gammell, R. T

Kenmare

Van Hook

Garrison, M. W.

.... Minot

Crosby

Rugby

Goodman, R.

Powers Lake

Minot

Halliday, D. J

Kenmare

Minot

Halverson, C. H . ...

Minot

Halverson, H. L.

Minot

Towner

Hanson, Geo. C.

Minot

Ittkin, Paul

Mohall

Johnson, C. G.

Rugby

Minot

Johnson, H. Paul

Minot

Johnson, O. W.

Rugby

Bottineau

Kaufmann, M. I. H.

Velva

Keller, E. T.

Rugby

Minot

Kermott, Louis H.

Minot

Knudson, K. O.

Kositsky, A.

Lampert, M. T

Malvey, Kenneth

McCannel, A. D. ...
McCannel, M. D. .
McIntosh, Hugh A.

O'Neill, R. T.

Parnall, Edward ....

Ransom, E. M.

Rowe, P. H.

Seiffert, G. S.

Sorenson, A. R. —

Stone, Oral, Jr

Timm, John F.

Wall, W. W

Wheelon, Frank

White, R. G.

Woodhull, R. B.

Yeomans. T. N. . .

Williston
Williston
... Crosby
Williston
Williston

Glenburn

Drake

Minot

Bottineau

Minot

Kenmare

Minot

Minot
.... Minot
Bottineau
... Makoti

Minot

RICHLAND COUNTY MEDICAL SOCIETY

president Bateman, C. V. Wahpeton Miller, H. H Wahpeton

Kellogg, I W. Fairmount Beithon, E. J. .... ... . Hankinson Reiswig, A. H. Wahpeton

secretary-treasurer Kellogg, I. W. Fairmount Thompson, A. H. Wahpeton

Reiswig, A. H. .... Wahpeton

SHEYENNE VALLEY MEDICAL SOCIETY

PRESIDENT

Cook, Paul T. Valley City

SECRETARY-TREASURER

Meredith, C. J. Valley City

Almklov, L. Cooperstown

Christianson, G. Valley City

Cook, Paul T Valley City

Dodds, G. A. Valley City

Gilsdorf, W. H. Valley City

Macdonald, A. C. .... Valley City
Macdonald, A. W. .... Valley City

Meredith, C. J. Valley City

Merrett, J. P. Valley City

Wicks, F. L. Valley City

September, 1946

311

PRESIDENT

Radi, R. B. Bismarck

SECRETARY-TREASURER

Pierce, W. B Bismarck

Arneson, C. A. Bismarck

Arnson, J. O. Bismarck

Baer, DeWiit . Steele

Baumgartner, C. Bismarck

Benson, O. T. ... Glen Ullin

Berg, H. M. Bismarck

Bertheau, H. J. .... Linton

Bodenstab, W. H. Bismarck

Boerth, E. H. _ Bismarck

Brandes, H. A. Bismarck

Brandt, A. M. .... Bismarck

Breslin, R. H. Mandan

Brink, Norvel .... Bismarck

Buckingham, T. W. Bismarck

Constans, G. M. Bismarck

DeMoully, O. M. Flasher

Diven, W. L. ____ Bismarck

SIXTH DISTRICT MEDICAL SOCIETY

Driver, D. R.

Fredricks, L. H.

Freise, P. W.

Gaebe, O. C. .

Bismarck

. .... Bismarck

Bismarck

New Salem

Griebenow, F.

Grorud, A. C.

Bismarck

Heffron, M. M. .... Bismarck

Heinzeroth, G. E. Turtle Lake

Henderson, R. W. Bismarck

Hetzler, A. E. Mandan

Hill, F. J. Minneapolis

Jacobson, M. S. Elgin

LaRose, V. J.

Larson, L. W

- Bismarck
Bismarck

Lipp. G. R. ..

Bismarck

Monteith, George

Moyer, I . B.

. Hazelton
Bismarck

Nickerson, B. S.

__ Mandan

Nuessle, R. F.

. Bismarck

Orr, August C.

. Bismarck

Owens, P. L.

Perrin, E. D.

- Bismarck
Bismarck

Pierce, W. B. ... Bismarck

Quain, E. P. .... Bismarck

Quain, F. D. __ Bismarck

Radi, R. B. Bismarck

Ramstad, N. O. Bismarck

Ray, R. H. .... Garrison

Roan, M. W. Bismarck

Rosenberger, H. P. Bismarck

Salomone, E. Elgin

Schoregge, C. W. Bismarck

Smith, C. C. Mandan

Smith, W. M. Bismarck

Speilman, G. H. Mandan

Strauss, F. B. Bismarck

Swingle, A. J. Mandan

Vinje, E. G. Hazen

Vinje, Ralph Beulah

Vonnegut, F. F. Linton

Waldschmidt, R. H. ... Bismarck

Weyrens, P. J. Hebron

Wheeler, H. A. Mandan

Williams, Maysil Bismarck

SOUTHERN DISTRICT MEDICAL SOCIETY

PRESIDENT

Wolfe, F. E. Oakes

SECRETARY-TREASURER

Meunier, H. J. . — . .... Oakes

Fergusson, F. W. Kulm

Fergusson, V. D. Edgeley

Lynde, Roy Ellendale

Meunier, H. J. __ Oakes

Miller, Samuel _ ... Ellendale

Mitchell, George Milnor

Van Houten, R. W. Oakes

Wolfe, F. E. Oakes

SOUTHWESTERN DISTRICT MEDICAL SOCIETY

PRESIDENT

Dukart, C. R. Richardton

SECRETARY-TREASURER

Reichert, H. L. _ Dickinson

Bloedau, E. L Santa Rosa, Calif.

Bowen, J. W. Dickinson

Chernausek, S. Dickinson

Dach, J. L. Hettinger

Dukart, C. R. Richardton

Gilsdorf, A. R. Dickinson

Guloien, H. E. Dickinson

Gumper, A. J. Dickinson

Hill, S. W. Regent

Lyons, M. W. Beach

Maercklein, O. C. Mott

Moreland, J. W New England

Murray, K. M. Scranton

Nachtwey, A. P. Dickinson

Olesky, E. Mott

Reichert, H. L. Dickinson

Rodgers, R. W. Dickinson

Schumacher, N. W. Hettinger

Schumacher, W. A Hettinger

Smith, O. S. Killdeer

Soules, M. E. New England

Spear, A. E. Dickinson

STUTSMAN COUNTY MEDICAL SOCIETY

Christiansen, H. A. Jamestown

Culbert, M. H. Medina

Cuthbert, W. H. .... Jamestown

DePuy, T. L. Jamestown

Fisher, A. M. Jamestown

Gerrish, W. A. Jamestown

Holt, G. H. Jamestown

TRAILL-STEELE MEDICAL SOCIETY

PRESIDENT

Nierling, R. D. Jamestown

SECRETARY-TREASURER

Larson, E. J. Jamestown

Arends, A. L. Jamestown

Arzt, Philip G. Jamestown

Carpenter, G. S. Jamestown

PRESIDENT

Dekker, O. D. Finley

SECRETARY-TREASURER

Vinje, Syver Hillsboro

PRESIDENT

Boyum, P. A. Harvey

SECRETARY-TREASURER

Seibel, L. J. Harvey

Beck, Charles J. Harvey

Boyum, P. A. Harvey

Cable, Thomas M. Hillsboro

Cleary, H. G. Sharon

Dekker, O. D. Finley

Kjelland, A. A. Hatton

TRI-COUNTY MEDICAL SOCIETY

Donker, A. E. Carrington

Ford, F. W. New Rockford

Hammargren, A. F Harvey

Matthaei, D. W. Fessenden

Moore, M. J. New Rockford

Larson, E. J. Jamestown

Nierling, R. D. Jamestown

Peake, Francis M. Jamestown

Roth, J. H. Jamestown

Sorkness, Joseph Jamestown

Wood, W. W. .. Jamestown

Woodward, F. O. Jamestown

Knutson, O. A. Buxton

LaFleur, H. A. Mayville

Little, R. C. Mayville

Vinje, Syver Hillsboro

Schwinghamer, E. J.

New Rockford

Seibel, L. J. __ Harvey

Van de Erve, H. Carrington

Westervelt, A. E. Bowdon

ROSTER

North Dakota State Medical Association-1946

AbPlanalp, I. S. Williston

Alger, L. J. Grand Forks

Almklov, L. Cooperstown

Arends, A. L. Jamestown

Arneson, Chas. A. Bismarck

Arnson, J. O. „ Bismarck

Arzt, P. G. Jamestown

Bacheller, S. C. Enderlin

Baer, DeWitt Steele

Baillie, W. F. Fargo

Bartle, J. P. Langdon

Bateman, C. V. .... Wahpeton

Baumgartner, Carl Bismarck

Beck, Charles A. Harvey

Beithon, Elmer J. Hankinson

Benson, O. T. .... Glen Ullin

Benson, T. Q. Grand Forks

Benwell, H. D. Grand Forks

Berg, H. M. Bismarck

Bertheau, Herman J. Linton

Blatherwick, W. D. Van Hook

Bloedau, E. L. Santa Rosa, Calif.

Bodenstab, W. H. Bismarck

Boerth, E. H. .... Bismarck

Bond, John H. .... Fargo

Borland, V. G. Fargo

Bowen, J. W. Dickinson

Boyum, P. A. ____ Harvey

Brandes, H. A. Bismarck

(retired)

i 12

The Journal Lancet

Brandt, A. M. ... ... Bismarck

Breslich, Paul J. Minot

Breslin, R. H. Mandan

Brink, N. O. .. Bismarck

Brown, Bernice E Grand Forks

Brown, G. F. Grand Forks

Buckingham, T. W. Bismarck

Burrows, F. N. Bathgate

Burt, A. C. Fargo

Burton, P. H. Fargo

Cable, Thomas M. . . Fdillsboro

Call, A. M. Rugby

Cameron, A. L. Minot

Campbell, R. D. Grand Forks

Canterbury, E. A Grand Forks

Carpenter, G. S. Jamestown

Carr, Andrew.. .... Minot (retired)

Caveny, K. P. Langdon

Chernausek, S Dickinson

Christiansen, FI. A. ...Jamestown
Christianson, Gunder ...Valley City

Clark, Ira D., Jr Casselton

Clay, A. J. Fargo

Clayman, Sidney G San Haven

Cleary, H. G. — . Sharon

Conroy, Martin P. ... Minot

Constans, G. M. Bismarck

Cook, Paul T. — Valley City

Countryman, G. L. — — Grafton
Countryman, J. E. Arch Cape, Ore.

Craise, O. S. Towner

Craven, Joseph D. Williston

Craven, John P Williston

Cronin, Donald J. Minot

Culbert, M. H. Medina

Cuthbert, W. H. . Jamestown

Dach, J. L. Hettinger

Dailey, Walter C Grand Forks

Darner, C. B. Fargo

Darrow, Frank Fargo

Darrow, Kent E. Fargo

Deason, Frank W. Grafton

DeCesare, F. A. Fargo

Dekker, O. D. Finley

DeMoully, Oliver M. Flasher

DePuy, T. L. Jamestown

Devine, J. I.., Jr. Minot

Devine, J. L., Sr. Minot

Dillard, J. R. Fargo

Diven, W. L. Bismarck

Dodds, G. A. Valley City

Donker, A. E. — Carrington

Downing, VC. M. Minot

Driver, D. R. Bismarck

Dukart, C. R. ... Richardton

Durnin, Charles Westhope

Dyson, Ralph E. Minot

Elofson, Carl E. Fargo

Engesather, J. A. D. ... Brocket

Erenfeld, Fred R. . ... Minot

Erenfeld, H. M. Minot

Fawcett, D. R. Devils Lake

Fawcett, John C. .... Devils Lake

Fawcett, Newton W Devils Lake

Fergusson, F. W. Kulm

Fergusson, V. D. Edgeley

Field, A. B. Forest River

Fischer, Verrill J. . Minot

Fisher, A. M. Jamestown

Fjelde, J. H Fargo

Fla ten, A. N. Edinburg

Flath, M. G. Stanley

Ford, F. W. New Rockford

Fortin, H. J. Fargo

Fortney, A. C. . Fargo

Foster, George C. Fargo

Fox, W. R. .. Rugby

Fredricks, L. H. Bismarck

Freise, P. W. .... Bismarck

French, H. E Grand Forks

Fritzell, K. E. Grand Forks

Fulton, A. M Minot

Gaebe, O. C. New Salem

Gammell, R. T. Kenmare

Garrison, M. W. Minot

Gerber, L. S. Crosby

Gerrish, W. A. ... . ... Jamestown

Gilsdorf, A. R. Dickinson

Gilsdorf, W. H. .... .... Valley City

Glaspel, C. J. Grafton

Goehl, R. O Grand Forks

Goodman, Robert Powers Lake

Graham, Chas. M Grand Forks

Graham, John D Devils Lake

Greene, E. E. Westhope

Greengard, M. Rolla

Griebenow, F. Bismarck

Griffin, V. M. Grand Forks

Grinned, E. L. Grand Forks

Gronvold, F. O. _ Fargo

Grorud, A. C. ... Bismarck

Guloien, Hans E. Dickinson

Gumper, A. J. Dickinson

Hagen, Edward J. Williston

Halliday, D. J. .... ... Kenmare

Halverson, C. H. ... Minot

Halverson, H. L. Minot

Hammargren, A. F. Harvey

Hanna, J. F. Fargo

Hanson, George C. Minot

Hardy, N. A. Minto

Haugen, C. O. Larimore

Haugrud, E. M. ... Fargo

Hawn, H. W. . Fargo

Heffron, M. M. Bismarck

Heilman, Charles O Fargo

Heinzeroth, G. Turtle Lake

Henderson, R. W. Bismarck

Hendrickson, G. Enderlin

Hetherington, J. E Grand Forks

Hetzler, A. E. Mandan

Hill, F. J. Minneapolis, Minn.

Hill, S. W. .. _ Regent

Holt, George H. .... Jamestown

Horsman, A. T. Devils Lake

(retired)

Hughes, B. J. .. . Rolla

Hunter, G. W. Fargo

Huntley, H. B. Kindred

Ittkin, Paul . — - Mohall

Ivers, George U. Fargo

Jacobson, M. S. Elgin

Jensen, A. F. Grand Forks

Johnson, Alan K. Williston

Johnson, C. G. Rugby

Johnson, H. Paul Minot

Johnson, O. W. Rugby

Joistad, A. H. Fargo

Jones, C. S. Williston

Kaufmann, M. I. H. .... Velva

Keller, E. T. Rugby

Kellogg, I. W. .... Fairmont

Kermott, Henry Minot

Kermott, L. H. Minot

Kjelland, A. A. Hatton

Klein, A. L. Fargo

Knudson, K. O. Glenburn

Knutson, O. A. Buxton

Korwin, J. J. Williston

Kositsky, A. Drake

LaFleur, H. A. Mayville

Lamont, J. G. Grafton

Lampert, M. T Minot

Lancaster, W. E. G. ... Fargo

Landry, L. H. ... Walhalla

LaRose, V. J Bismarck

Larson, E. J. Jamestown

Larson, G. A _ Fargo

Larson, L. W. Bismarck

Leigh, R. E. Grand Forks

Lewis, T. H. Fargo

Liebeler, W. A. Grand Forks

Lipp, G. R. Bismarck

Little, R. C. Mayville

Lohrbauer, L. T Grand Forks

Lommen, C. E. Fordville

Long, W. H. Fargo

Lund, C. M. Williston

Lynde, Roy Ellendale

Lyons, M. W Beach

McCannel, A. D Minot

McCannel, M. A. Minot

Macdonald, A. C Valley City

Macdonald, A. W. .... Valley City

MacDonald, J. A. Cando

McIntosh, H. A. Kenmare

McKeague, D. H. Maddock

McPhail, C. O. Crosby

Maercklein, O. C. Mott

Mahowald, R. E. Grand Forks

Malvey, Kenneth Bottineau

Matthaei, D. W. Fessenden

Mazur, B. A. Fargo

Meredith, C. J __ Valley City

Merrett, J. P. Valley City

Meunier, H. J. ^ Oakes

Miller, H. H. Wahpeton

Miller, H. W. Casselton

Miller, Samuel Ellendale

Mitchell, George Milnor

Monteith, George Hazelton

Moore, John H. .... Grand Forks

Moore, M. J. New Rockford

Moreland, J. W. New England

Morris, A. C Fargo

Moyer, L. B. Bismarck

Mulligan, V. A. Langdon

Murray, K. M. Scranton

Muus, O. H. Grand Forks

Nachtwey, A. P Dickinson

Nichols, A. A. Fargo

Nichols, W. C. Fargo

Nickerson, B. S. Mandan

Nierling, R. D. Jamestown

Nuessle, R. F. Bismarck

Oftedal, Trygve Fargo

Olesky, Elmer Mott

O’Neill, R. T. Minot

Orr, August C. Bismarck

Ostfield, J. R. Fargo

Owens, P. L Bismarck

Palmer, D. W Cando

Panek, A. F. Milton

Parnall, Edward ____ Minot

Patterson, T. C Lisbon (retired)

Peake, Francis M. Jamestown

Peake, Margaret F Grand Forks

Perrin, E. D. Bismarck

Pierce, W. B. . Bismarck

Pray, L. G. Fargo

Quain, E. P. Bismarck

Quain, Fannie D. Bismarck

Quale, V. S. Grand Forks

Radi, R. B. Bismarck

Ramstad, N. O. Bismarck

Rand, C. C Grafton

Ransom, E. M. Minot

Ray, R ,H. Garrison

Reed, Paul Rolette

Reichert, H. L. Dickinson

Reiswig, A. H. Wahpeton

Richter, E. H. Hunter

Roan, M. W. ... Bismarck

September, 1946

313

Rodgers, R. W.

Dickinson

Soules, Mary E. W.

New England

Vollmer, Fred J.

Grand Forks

Rosenberger, H. P.

Bismarck

Spear, A. E.

Dickinson

Vonnegut, F. F.

....... Linton

Roth, J. H. . -

Jamestown

Spielman, G. H.

Mandan

Waldren, G. R.

Cavalier

Rowe, P. H.

Minot

St. Clair, R. T.

Northwood

Waldren, H. M., Jr.
Waldschmidt, R. H..

Drayton

Ruud, H. O.

Grand Forks

Stafne, Wm. A. ...
Stickelberger, Joseph

Fargo

Bismarck

Ruud, John E.

Devils Lake

ine Oberon

Wall, W. W.

Minot

Ruud, M. B

Grand Forks

Stolinsky, A.

San Francisco

Watson, E. M.

Fargo

Salomone, E. J.

.... Elgin

Stone, Oral H., Jr.

Bottineau

Weed, F. E.

Park River

Savre, M. T. ..

... Northwood

Stratte, J. J.

Grand Forks

Weible, R.

Fargo

Schoregge, C. W. ...

Bismarck

Strauss, F. B.

Bismarck

Welch, W. F... Larimore (retired)

Schumacher, N. W.

Hettinger

Swanson, J. C.

Fargo

Westervelt, A. b.

Bowdon

Schumacher, W. A.

Hettinger

Swingle, Alvin J. ...

Mandan

Weyrens, P. J.

Hebron

Schwinghamer, E. J.

Fainter, Rolfe

Fargo

Wheeler, H. A.

Mandan

New Rockford

Thompson, A. M. ...

Wahpeton

Wheelon, F. E.

Minot

Sedlak, O. A.

. .... Fargo

Thorgrimson, G. G.

Grand Forks

White, R G

Minot

Seibel, L. J.

Makoti

Wicks, F L.

... Valley City

SeifFert, G~. S. ... ...

Minot

Tompkins, C R.

Grafton

Williams, Maysil

Bismarck

Sihler, W. F.

Devils Lake

Toomey, G. W.

... Devils Lake

Williamson, G. M. ...
Witherstine, W. H.

. Grand Forks

Silverman, Louis .

Grand Forks

Tronnes, Nels

Fargo

Grand Forks

Skelsey, A. W.

Urenn, B. M.

Fargo

Wolfe, F. E.

Oakes

Skovholt, H. T.

Williston

Vance, R. W

Grand Forks

Wood, W. W.

Jamestown

Smith, C. C.

Mandan

Van de Erve, H.

.... Carrington

Woodhull, R. B.

Minot

Smith, Clinton

Devils Lake

Van Houten, R. W.

Oakes

Woodward, F. O. ...

Jamestown

Smith, 0. S.

Killdeer

Vigeland, J. G.

Brinsmade

Woutat, P H

. Grand Forks

Smith, Wm. M.

Wright, W. A. ...

Williston

Sorenson, A. R.

Yeomans, T. N. .

Minot

Sorkness, Jos.

.... Jamestown

Vinje, Syver

Hillsboro

Youngs, Nelson A.

Grand Forks

. . . (HEET OUR COflTRIBUTORS . . .

Dr. Wesley W. Spink has been associated with the
University Hospitals, Minneapolis, Minnesota, since
1937. He is a graduate of Harvard Medical School,
class of 1932, with A.B. and M.D. degrees, and did
graduate work there from 1934 to 1937. His specialty
is internal medicine. He is president of the Minnesota
Pathological Society, secretary of the American Society
for Clinical Investigation, member of the American Asso-
ciation of Physicians, Minnesota State Medical associa-
tion, and the Hennepin County Medical society. During
World War II he was consultant to the Secretary of
War on epidemic diseases and a member of the Com-
mission on Hemolytic Streptococcus Diseases.

Dr. Owen Wangensteen, chief of the Department
of Surgery, University of Minnesota Medical School,
is a frequent and valued contributor to Journal Lancet.

Donald J. Pletsch is Associate Entomologist at the
Montana Agricultural Experiment Station, Bozeman.
He is a graduate of the University of Minnesota, receiv-
ing his M.S. in 1936 and his Ph.D. in 1942. He is a
member of Sigma Xi.

Bwlc lUviews

Electrocardiography in Practice, by Ashton Graybird,
M.D., and Paul D. White, M.D. Second edition, 458
pages with 323 illustrations. Philadelphia: W. B. Saunders
Co., 1946. $7.00.

The first edition of this worth-while volume was very well
received when it was published a few years ago. Recent ad-
vances in clinical electrocardiography, however, have made this
new second edition necessary.

The general style of presentation of the material has not
changed any. Many revisions have been made, and greater em-
phasis than heretofore has been placed upon the interpretation

of normal patterns. A larger number of records, illustrating
both normal and abnormal conditions, have been included, as
well as a new series of test electrocardiograms for practice in
interpretation.

This book should be of great value to everyone interested in
electrocardiography, the cardiologist, internist, as well as the
general practitioner. T. Z.

Pneumoperitoneum Treatment, by Andrew Ladislaus
Banyai, M.D., F.A.C.P., F.C.C.P.; Associate Clinical Pro-
fessor of Medicine, Marquette University Medical School,
Milwaukee, Wisconsin; Member, Editorial Board, Diseases
of the Chest; formerly Preceptor in Tuberculosis, School of
Medicine, University of Wisconsin, Madison, Wisconsin.
With 74 illustrations. St. Louis: C. V. Mosby Company,
1946. $6.50.

During the past few years pneumoperitoneum has increased
in popularity and its uses have been somewhat extended. There-
fore, it is fitting that Banyai should have prepared this mono-
graph. In the historical review he calls attention to the pro-
cedure having its origin in 1872 when, in the course of a lap-
arotomy for another purpose, tuberculous peritonitis was dis-
covered, from which the patient completely recovered following
the surgery. Subsequently, laparotomy was strongly recom-
mended for tuberculous peritonitis, as it was thought that the
air and light so introduced had a favorable influence on the
disease. In 1893 oxygen was injected intraperitoneally for the
treatment of peritonitis. Since that time a large number of
physicians have introduced oxygen or filtered air into the peri-
toneal cavity for the treatment of this condition.

In this monograph, Banyai presents chapters on the use of
pneumoperitoneum in such conditions as tuberculous entero-
colitis, tuberculous empyema, tuberculous salpingitis, pulmonary
abscess, bronchial asthma, bronchiectasis, pulmonary emphys-
ema, pulmonary hemorrhage and pulmonary tuberculosis. In
these chapters he includes the indication and the results of the
treatment as reported by various authors. Chapters are included
on technique of administration, physiological changes following
pneumoperitoneum, air embolism and mediastinal emphysema
as complications. This book of 376 pages is a thoroughgoing
presentation of pneumoperitoneum. It is well illustrated and
contains a fine bibliography and index. The author, who has
long been recognized as an authority on this subject, is to be
congratulated on making such a complete presentation of the
subject in such concise and readable form. This book should
be available to all physicians in the field of tuberculosis and
chest diseases in general. All other physicians can read the
book with profit. J. A. M.

Serves the

MINNESOTA, NORTH DAKOTA,

Medical Profession of

SOUTH DAKOTA and MONTANA

ADVISORY COUNCIL

North Dakota State Medical Assn.
Dr. James F. Hanna, Pres.

Dr. A. E. Spear, Pres. -Elect
Dr. L. W. Larson, Secy.

Dr. W. W. Wood, Treas.

North Dakota Society of
Obstetrics and Gynecology
Dr. Paul Freise, Pres.

Dr. G. Wilson Hunter, Vice Pres.
Dr. F. A. DeCesare, Secy.-T reas.

Minneapolis Academy of Medicine
Dr. Russell W. Morse, Pres.

Dr. Paul F. Dwan, Vice Pres.

Dr. J. C. Miller, Secy.

Dr. Ragnvald S. Ylvisaker, T reas.
Dr. Henry E. Hoffert, Recorder

South Dakota State Medical Assn.
Dr. F. S. Howe, Pres.

Dr. H. R. Brown, Pres. -Elect
Dr. J. L. Calene, Vice Pres.

Dr. Roland G. Mayer, Secy. -Treas.

South Dakota Public Health Assn.
Dr. J. M. Butler, Pres.

Dr. C. E. Sherwood, Vice Pres.

Dr. Gilbert Cottam, Secy. -Treas.

Sioux Valley Medical Assn.

Dr. D. S. Baughman, Pres.

Dr. Will Donahoe, Vice Pres.

Dr. R. H. McBride, Secy.

Dr. Frank Winkler, Treas.

BOARD OF EDITORS

Dr. J. A. Myers, Chairman

Montana State Medical Assn.

Dr. M. A. Shillington, Pres.

Dr. L. W. Allard, Pres.-Elect
Dr. H. T. Caraway, Secy .-Treas.

Northwestern Pediatric Society
Dr. G. B. Logan, Pres.

Dr. Geo. Kimmel, Vice Pres.

Dr. Northrop Beach, Secy.-T reas.

Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.

Dr. R. C. Webb, Secy. -Treas.

American Student Health Assn.

Dr. Ralph I. Canuteson, Pres.

Dr. Laurence Chenoweth, Vice Pres.
Dr. G. T. Blydenburgh, Secy.-T reas.

Dr. J. O. Arnson
Dr. A. B. Baker
Dr. D. S. Baughman
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W. A. Fansler

Dr. A. R. Foss
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. J . Mabee

Dr. J . C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C. H. Nelson
Dr. N. J . Nessa
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. C. E. Sherwood

Dr. M. A. Shillington
Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. S. E. Sweitzer

Dr. W. H. Thompson
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin,
Secretary

LANCET PUBLISHING CO., Publishers, 84 South Tenth St., Minneapolis 2, Minnesota

Minneapolis, Minnesota, September, 1946

CO-OPERATIVE HEALTH UNIT
ORGANIZED

A number of delegates from various co-operative
groups met in the first national conference on Co-Opera-
tive Health Plans at Two Harbors, Minnesota, August
15th, 1946, in a four day session for the purpose of set-
ting up a new organization to be known as the Co-
Operative Health Federation of America. Participants
at the meeting included Charles Wilkenson, president of
the Two Harbors Health Center, George W. Jacobson,
Group Health Mutual, St. Paul, and Gladys Edwards,
Farmers Union Terminal Association. A paper by Dr.
James P. Warbasse, who is known as a "lecturer on
co-operation” and president emeritus, the Co-Operative
League, U.S.A., was read. Dr. Kingsley Roberts, di-
rector, Medical Administration Service, Inc., New York
City, spoke on administrative phases of co-operative
medicine. The Rev. M. M. Coady, extension depart-
ment, St. Xavier University, Antigonish, Nova Scotia,

gave an address on "Mobilizing the People for Democ-
racy through Co-operation.”

The conference approved by a resolution "the prin-
ciple of public responsibility for assuring the availability
of health and medical services for all the people without
economic or other barriers.” The Principles of Medical
Ethics of the American Medical Association unequivo-
cally states "The poverty of a patient should command
the gratuitous services of a physician.” We do not know
what the "other barriers” refer to. The real purpose of
the organization as its name would imply is simply to
put the cost of medical care on a co-op>erative basis, and
we understand that co-operative groups enjoy certain tax
exemption benefits.

Dr. Haven Emerson, professor emeritus of public
health, Columbia university, New York City, was prin-
cipal speaker at a dinner meeting climaxing the session
of the new organization and took occasion to criticise the
Murray-Wagner-Dingell public health bill, declaring that

September, 1946

315

it would lower the quality of medical care while increas-
ing its cost. He charged that the term "public health”
as used by Sir William Beveridge and "that trio of im-
practical political propagandists, Murray, Wagner and
Dingell” implies services and promises that cannot be
fulfilled under any financial or administrative structure
proposed to date. He advised a program of co-opera-
tion of patients with their physicians self-chosen groups,
and "Let us from now forward discard the dishonest,
politically inexpedient, but misleading and intellectually
deceptive and confusing term, 'health insurance’ and
commit ourselves at least at the present stage of our im-
mediate and pressing concern to insurance that medical
care will be available and paid for.”

When Ray Lyman Wilbur was Secretary of the In-
terior fifteen years ago, he said "Why physicians prac-
tice charity toward those unfortunate people who belong
to the whole community, is beyond the understanding of
anyone except a doctor who has been accustomed to it,
and the people who have been taking it for granted.
Nobody else does it; and yet we go on, with these com-
plicated economic conditions, at a time when the condi-
tions in every direction are compelling us to consider eco-
nomics as never before. We have on the one hand much
talk regarding the high cost of medical service and on
the other hand many people who fail to pay their hos-
pital and medical bills promptly if at all. It would be
possible to improve this chaotic situation very much if
the whole business were handled intelligently.”

Physicians are not averse to getting paid for their
services but they squirm a bit at the thought of outsiders
arranging the program and handling the gate receipts.

A.E.H.

THE TRANSMISSION OF POLIOMYELITIS

Although thirty-eight years have elapsed since Landsteiner
and Popper first demonstrated clearly the virus etiology of polio-
myelitis, controversy persists regarding the mode of spread of
1 the infection. During outbreaks such as the present one in the
midwest this controversy forces itself clearly upon the attention
of medical and lay personnel alike and becomes of paramount
importance in motivating the public to demand control measures
consistent with the varied ideas as to mode of transmission.
It is well therefore to examine briefly the several hypotheses that
j j are most commonly held.

IThe earliest and still the most widely accepted hypothesis is
that poliomyelitis is spread through the secretions of the nose
and throat, thus spreading in a manner comparable to measles,

[smallpox or other respiratory-spread infections. The virus has
been isolated repeatedly from the upper respiratory tract of
paralyzed cases, non-paralytic cases, abortive infections and fam-
ily contacts of cases. The monkey (the only animal susceptible
to all strains) can be infected more readily by intranasal instilia-

Ition than by any other normal avenue of entry. There can be
little doubt therefore of the possible spread through respiratory
exchange.

The distribution of cases, as well as of persons carrying anti-
bodies, is consistent with the well recognized patterns of respira-
tory-spread diseases. Infection appears earlier in life in urban
than in rural areas, a phenomenon not characteristic of infec-
tions spread through the gastrointestinal tract or by insects.
The evolution of an outbreak is also typical according to the
respiratory pattern, cases spreading outward in concentric circles

from various foci of infection. Where the disease appears first
it ends first, where it begins late it ends late.

Against the respiratory hypothesis is the frequently raised
argument of seasonal occurrence, an argument based on the
erroneous concept that there is a characteristic winter peak of
other respiratory infections. In reality diphtheria usually reaches
its peak in November, the month which is most commonly the
month of minimum incidence of whooping cough, while chicken-
pox reaches its peak in December or January, scarlet fever in
March and measles in May. There is thus no standard respira-
tory pattern. On the contrary the peak of poliomyelitis more
closely approximates that of diphtheria than does measles.

A second hypothesis which has attracted much attention dur-
ing recent years is that of spread through the alimentary tract,
an hypothesis of considerable antiquity, but most recently re-
advanced and championed by Trask and Paul. These investi-
gators demonstrated that the virus can be found very readily
and in large quantity in the feces of all types of cases and of
familial contacts and that it can be isolated from sewage.
Furthermore isolation from the stool is accomplished more
readily than from the respiratory tract and the virus can be
shown to persist in the intestinal tract for several months after
recovery. The similarity in seasonal curves of poliomyelitis and
typhoid has been advanced as further evidence of intestinal
spread.

Against this hypothesis is the fact that no outbreak of polio-
myelitis consistent with the idea of spread through water has
ever been reported, for the disease occurs and spreads without
reference to distribution of water supplies. Food-borne infec-
tions are likewise highly problematical. The hypothesis would
explain a few isolated and very minor outbreaks but could never
explain the radial spread of infection from the initial foci or the
well recognized migration of the disease from one part of the
country to another in successive years. The presence of tubercle
bacilli or of pneumococci in the stool certainly does not indicate
intestinal spread of those infections.

A third hypothesis is that of insect-spread. It is true that on
two or three occasions virus has been recovered from flies having
access to sewage from which virus could likewise be isolated, an
observation of considerable interest but hardly adequate to war-
rant the assumption that flies are the chief vector and that their
destruction through DDT spraying will stop an outbreak. The
summer incidence of poliomyelitis has been advanced in further
support of insect-spread, as has also the mistaken idea that out-
breaks cease abruptly with the advent of frost. This latter idea
is without support, for the curve of the outbreak is not altered
in the least by frost or other abrupt seasonal changes. On the
contrary it may frequently rise after frost, if the outbreak has
begun late in the season. The Melbourne, Australia, outbreak
of 1937 began shortly after the most severe series of frosts in
the history of that area. Winter outbreaks are far from rare.

It is apparent from the above that strong and compelling
arguments can be raised against the hypothesis of spread by
insects or the alimentary tract as mechanisms which explain the
general occurrence of poliomyelitis. No one would deny that
an occasional case might be so transmitted, but the hypothesis
of respiratory-spread remains the only one consistent with the
known facts and adequate to account for the general spread of
infection throughout the community as a whole.

So long as we thought of poliomyelitis only in terms of para-
lytic cases, the respiratory hypothesis was grossly inadequate.
Today, however, we recognize that infection with the polio-
myelitis virus is probably as common as measles, but that only
a few persons respond with paralytic manifestations. The rest
of us appear to acquire resistance from this infection, which is
usually so mild as to cause no symptoms and therefore such
cases escape recognition. It is not improbable that the mystery
of poliomyelitis may be found not in the study of mechanisms
of spread but of those individual physiological factors that de-
termine the human response to the virus. Why is it that a few
persons respond with neurologic involvement and paralysis while
for most of us infection with the virus is a minor affair that
immunizes without sickening?

Gaylord Anderson, M.D.,

University of Minnesota

316

The Journal Lancet

Views Itetns

The 68th annual meeting of the Montana State Med-
ical Association was held July 18-20 at Great Falls, Mon-
tana. Dr. M. A. Shillington of Glendive was elected
president, and Dr. L. W. Allard of Billings, president-
elect. Dr. C. H. Frederickson of Missoula was named
vice-president, and Dr. Fd. T. Caraway of Billings, sec-
retary. Delegate to the A.M.A. convention is Dr. R. T.
Peterson of Butte, with Dr. Thomas Fdawkins of Fdelena
first alternate.

Guest speakers at the scientific session were Dr. John
A. Anderson, Salt Lake City, professor and head of the
department of pediatrics, University of Utah, "Fferpetic
Infections in Infants and Children” and "Quantitative
Aspects of Fluid Therapy in Infants and Children”;
Dr. Charles E. McLennan, Salt Lake City, professor
and head of the department of obstetrics and gynecology,
University of Utah school of medicine, "Gynecologic
Bleeding” and "Pregnancy in Diabetes”; Dr. O. Theron
Clagett, assistant professor of surgery, University of
Minnesota, and head of section, division of surgery,
Mayo Clinic, Rochester, "Surgery of the Stomach” and
"Surgery of the Aged”; Dr. Emil Goetsch, New York
City, professor of surgery, Long Island College of Medi-
cine, "Surgery of the Thyroid”; Dr. Byron E. Hall,
assistant professor of medicine, University of Minnesota,
and department of medicine, Mayo Clinic, Rochester,
"Effect of Folic Acid on the Macrocytic Anemias” and
"Radioactive Phosphorous Therapy”; Dr. Kenneth Swan,
Portland, Oregon, professor and head of the department
of ophthalmology, University of Oregon medical school,
"Eye Emergencies”; Dr. Walter S. Priest, Chicago, asso-
ciate in medicine, Northwestern University school of
medicine, and Dr. Eugene Hildebrand, Great Falls, Mon-
tana, formerly pathologist at Passavent Memorial Hos-
pital, Chicago, "Antibiotic Therapy of Sub-acute Bac-
terial Endocarditis with Autopsy Findings in Ten Cases.”

The Montana Academy of Oto-Ophthalmology held
the 47th semi-annual meeting in Great Falls in conjunc-
tion with the Montana State Medical Association July
17-18. Dr. Kenneth Swan, Professor of Ophthalmology
of the University of Oregon Medical School, presented
two papers with illustrated slides in color "Tumors of
the Eye and Adnexa” and "Infections of the Eye.” Dr.
Robert Movius of Billings and Dr. F. H. Burton of
Butte were elected to active membership. The next meet-
ing of the Academy will be held in Lewistown, February
22-23, 1947.

Dr. William C. Bernstein has reopened offices at 934
Lowry Medical Arts building, St. Paul, Minnesota, for
the practice of proctology. Dr. Bernstein has recently
returned from the armed services where he was a major
in the army medical corps, and was the proctologist at
the Oak Ridge hospital, Oak Ridge, Tennessee, which
served the personnel of the atomic bomb project. Dr.
Bernstein will also resume his clinical work at the Uni-
versity of Minnesota hospital.

Dr. Ruth E. Taylor has resigned as Director of the

Health Service, University of Chicago, Illinois. Dr.
Clayton Loosli has been appointed to replace her.

The annual convention of the National Association of
Coroners will be held in Minneapolis, Minnesota, Sep-
tember 26-27-28, 1946, at the Nicollet Hotel. Dr. Rus-
sell R. Heim of Minneapolis is chairman. Speakers from
many states will participate in the scientific program.
There will also be a series of round table discussions to J
be held at the luncheons.

Dr. A. V. Stoesser, Minneapolis General Hospital,
Minnesota, was appointed representative to the Scientific
Exhibit from the section on Pediatrics for the 1947 ses-
sion at the recent meeting of the American Medical As-
sociation in San Francisco. He was also elected chairman
of the Committee of Press Releases and to the editorial
board of the "Annals of Allergy” at the meeting of the
American College of Allergists in San Francisco which
preceded that of the A.M.A.

Dr. Frank H. Alexander, 78, St. Paul, Minnesota,
died August 3. He was a member of the Ramsey Coun-
ty Medical Society and the Minnesota State Medical
Association. He is survived by a daughter.

Dr. Arnold L. Hamel, 58, a Minneapolis physician for
32 years, died July 31. He was on the staff of St.
Mary’s hospital, and was a member of the Hennepin
County Medical Society, Minnesota State Medical As-
sociation, and the American Medical Association. Sur-
viving are his wife, five daughters and five sons.

Dr. Frederick B. Strauss, 67, pioneer physician in
Bismarck, North Dakota, died July 26. He was first
secretary of the sixth district unit of the North Dakota
State Medical association and past president of the same
organization. Surviving are his wife, two sons, and a
daughter.

Dr. Hans Haugen, 70, who practiced in Fargo, North
Dakota, since 1918, died July 11. He was born in Nor-
way in 1875. He left there at the age of 16 to live in
Abercrombie, North Dakota. He attended Fargo Col-
lege and was a graduate of Northwestern University
medical school, 1906. He is survived by his wife, two
sons, and a daughter.

Dr. J. E. Shull, 77, physician in Alpena, South Da-
kota, since 1901, died July 12. He is survived by his
wife and one sister.

Dr. Nels A. Gunderson, 50, who practiced surgery
in Minneapolis, Minnesota, for 26 years, died July 17.
He was a member of the A.M.A., Hennepin County
Medical Association, and was at one time chief of staff
of Swedish hospital. He is survived by his wife, three
sons, and a sister.

Dr. Joseph M. Hall, 58, practicing physician in Min-
neapolis for 32 years, died July 19. Surviving are his
wife, his mother and one son.

Dr. G. W. Glaspell, 81, Grafton, North Dakota, died
June 27, after 58 years as practicing physician in that
community. He is survived by his wife, a daughter,
and a son.

WHEN VITAMIN K IS NEEDED...

Synkayvite* 'Roche' is the choice of many physicians
because of its distinctive clinical advantages. Synkayvite is water-
soluble, stable and — molecule for molecule — has "an antihemor-
rhagic activity even greater than that of fat soluble menadione"
(J. G. Allen, Am. J. M. Sc., 205:97, 1943). It may be taken orally
without the use of nauseous bile salts or administered paren-
terally. Synkayvite is available in oral tablets, 5 mg each, and
1-cc ampuls, 5 mg and 10 mg each.

Hoffmann-La Roche, Inc., Nutley 10, New Jersey

* 2-methyl~1, 4‘naphthohydroquinone
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SYNKAYVITE

'ROCHE'

318

The Journal Lancet

Cto&sified Adv&iti&emeHts

PHYSICIAN WANTED

Wanted: physician to join the medical staff of the
North Dakota State Hospital. If interested correspond
with Superintendent, North Dakota State Hospital,
Jamestown, North Dakota.

TECHNICIAN WANTED

Female technician who can do laboratory and x-ray
work, in medical firm situated in lake region of Minne-
sota. Good salary from the start. Address Box 846, care
of this office.

ATTENTION DOCTORS— DENTISTS

Available modern offices equipped with gas and com-
pressed air in well established medical center on West
Broadway, Minneapolis, Minnesota, serving a large resi-
dential community. Address Box 761 A, care of this office.

GENERAL PRACTICE FOR SALE

Montana, midway between Yellowstone and Glacier
National Parks. Gross $3 5,000. Fully equipped office.
Excellent hospital facilities. Fine home, 4 bedrooms, oil
heat, garage. Immediately available. Write for particu-
lars. John J. Elliott, M.D., Lewistown, Montana.

ASSISTANT WANTED

ASSISTANCE AVAILABLE

Aznoe’s, established in 1896, has available a number
of well trained physicians (diplomates of the specialty
boards, industrial physicians and surgeons, general prac-
titioners, psychiatrists, tuberculosis specialists and resi-
dents). For histories, write Ann Woodward, Aznoe’s-
Woodward Medical Personnel Bureau, 30 North Michi-
gan Ave., Chicago 2, III.

SOUTH DAKOTA PHEASANT GUIDE

The original South Dakota pheasant guide, prepared espe-
cially to help out-state hunters plan their trips to South Da-
kota’s famed hunting grounds and advertised elsewhere in this
issue, offers an extra service this year by securing licenses for
hunters in advance of the season, unofficially scheduled to open
October 15. Each guide book contains a license application
form, in addition to giving full information on hunting condi-
tions, hotels, travel facilities, gunsmiths, locker plants, laws and
regulations, plus a fund of facts gotten up by experts, on guns,
ammunition, dogs, preservation of birds and preparation for the
dining table. The guide is endorsed by South Dakota game
commissioner Peterson. Extra license applications and reserva-
tions for the guide may be made by writing to Madison, S. D.

Philcapco’s DIAVETANS

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Diet and the Liver

Harry O. Drew, M.D.
Billings, Montana

The liver finally seems to be assuming the impor-
tant role in the physiology of the body which its
size warrants. For many centuries, the main liver func-
tion was believed to be the formation and secretion of
bile. Eventually, Claude Bernard called attention to its
ability to store carbohydrates as glycogen and the release
of this glycogen as glucose.

During the last twenty-five years, the intense studies
which were made relative to food chemistry have brought
out the significance of the liver in metabolism, and have
revealed the following more or less interlocking functions
of the liver:

1. Bile formation.

2. Formation and destruction of red blood cells
(with its relationship to jaundice) .

3. Protein metabolism.

4. Fat metabolism.

5. Carbohydrate metabolism.

6. Antitoxic and protective functions.

7. Blood coagulation and vitamin K relativity.

8. Formation of fibrinogen.

As the oldest known, and most spectacular of these
functions, bile formation should be considered first.
Bile is composed of bile pigments, bile salts, cholesterol,
lecithin and mucin. The bile pigment, bilirubin, is
formed from hemoglobin from destroyed red blood cells
by the reticulo-endothelial cells. It is excreted by the
liver cells into the bile capillaries. Biliverdin is formed in
the bile capillaries by oxidation of bilirubin. The bile salts,
sodium taurocholate and sodium glycocholate, are salts
of cholalic acid which is closely related to cholesterol and
ergosterol. The taurocholates are derived from taurine

Read before the Billings Clinical Association, April 19, 1946,
Billings, Montana.

and cholalic acid. Taurine is probably derived from cys-
tine as it contains sulphur. The glycocholates are derived
from cholalic acid and the amino-acid glycine.1

Cholesterol, which is found in nearly all body tissues,
varies in amount in the bile directly in proportion to
that found in the blood.1 Some tissues have rather large
amounts present. These are the suprarenal glands, the
ovaries, and the brain. While it is ingested in foods,
especially egg-yolk, butter and other fats, and pork,
there is reason to think that some is formed in the body.
This is proven by the fact that on some diets the output
of cholesterol is greater than the intake. In some dis-
eases the blood-cholesterol greatly increases. There is no
direct evidence that the cholesterol is formed by the liver.
It may be a secretion from the blood.1 Cholesterol is
so closely related chemically to the androgens, the estro-
gens, and the cortico-adrenal hormone that it may be
the "mother substance” from which they are derived.-’
The mucin found in bile seems to be a secretion from
the epithelium of the gallbladder.

Bile secretion is dependent on food intake to a great
extent because during fasting the secretion is reduced
to a minimum. High protein feeding raises the bile salt
excretion to a maximum. The bile salts are largely re-
absorbed by the intestine. This is also true of the choles-
terol content of the bile. Bile function in the intestinal
tract seems to be to aid in the emulsification of fat and
to facilitate the actions of the pancreatic enzymes.

Fat metabolism and liver function have interesting
relationships. The liver desaturates fatty acids and forms
phospholipines by combining them with phosphoric acid
and nitrogenous bases. The phospholipines are then sent
to the tissues where they are utilized. The amount of
fat present in the liver is usually about 3 per cent. This

310

320

The Journal-Lancet

varies, however, dependent on diet or disease.1 A high
fat diet will produce an increase in liver fat as will a
high carbohydrate diet. Paradoxically, fasting will pro-
duce a temporary increase in liver fat/ Pyridoxine and
biotin or vitamin H and some of the synthetic estrogens
have been blamed for fatty infiltration of the liver. Pro-
longed fatty infiltration of the liver is blamed by some
investigators for the development of cirrhosis.'1

The storage of carbohydrate in the liver is one of the
best known of the liver functions. It occurs in the liver
as glycogen or "animal starch” with a formula of C<;-
H10O5. It is readily converted into glucose (CijHi^Og)
and serves as a reservoir for blood sugar and a quick
source of energy. The source of liver, as well as muscle,
glycogen is the sugars and starches from food and the
non-nitrogenous residue from protein digestion. Fat does
not seem to be a source of glycogen. When glucose sup-
plies are inadequate, the complete combustion of fats to
carbon dioxide and water does not take place, and the
"ketone bodies” b-oxybutyric acid and aceto-acetic acid
are formed. 1 Carbohydrates therefore are antiketogenic
and act as an aid in completing fat combustion. The
glycerine of fat and the carbohydrate from protein diges-
tion serve in a similar manner. As we shall see later,
an important function of carbohydrates is to spare the
use of proteins for more important uses.

When we consider the problem of protein metabolism
and the role the liver plays in this complicated subject,
we find that all of the liver functions are interlocked
with it. Some of these are the antitoxic and protective
actions through the formation of the globulins, the
role it plays in blood coagulation by the formation of
prothrombin and fibrinogen, the probable formation of
hemoglobin and the maintaining of normal proteinemia.

The products of protein digestion reach the liver by
the portal vein as amino-acids. These are substances
which are essentially organic acids with an amino group
attached. Many years ago, Emil Fischer was able to
combine a number of these amino-acids into compounds
with all of the properties of polypeptids. This is unques-
tionably the manner in which the liver synthesizes the
body proteins. Some of the amino-acids pass directly
into the general circulation and are utilized by tissue
cells to build up the substance worn down by their activ-
ity.1 Other amino-acids are de-aminized and the am-
monia is converted into urea by the liver cells. All urea
is formed in the liver and excreted by the kidneys, and
the amount found in the urine is an indication of the
amount of nitrogenous matter ingested as food. Nor-
mally, there is a distinct balance between the amount
of nitrogenous matter ingested and the amount lost by
excretion. The de-aminized residue of the amino-acids
is utilized by the liver as carbohydrates. Others of the
amino-acids are synthesized by the liver into proteins
which are essential to body metabolism.

Among the proteins synthesized by the liver are the
so-called plasma proteins. These consist of at least six
proteins — two albumens, three globulins, fibrinogen (a
globulin possessing distinctive chemical and physical char-
acteristics), and prothrombin. Much evidence has been
accumulated concerning the formation of plasma pro-

teins in dogs by means of an Eck fistula. This is done
by anastomosing the portal vein with the inferior vena
cava. This, of course, cuts off the supply of blood to
the liver from the intestines and the plasma proteins are
rapidly depleted. Another method for the study of
plasma protein formation in the dog is plasmapheresis
which consists in exsanguination of the dog and the re-
injection of the washed red blood cells. By feeding these
dogs various types of proteins and mixtures of amino-
acids, and estimating the amounts of plasma proteins
as they appear in the blood, much valuable information
has been gained.

While about forty amino-acids have been identified,
but twenty-two of them have been found to be nutri-
tionally important. These have been divided into the
essential and the non-essential amino-acids. Rose1’ gives
the following list of the nutritionally important amino-
acids:

Essential:

Arginine

Histidine

Isoleucine

Leucine

Lysine

Methionine

Phenylalanine

Threonine

Tryptophan

Valine

Non-essential:

Alanine

Aspartic acid

Citrulline

Cystine

Glutamic acid

Hydroxyglutamic acid

Hydroxyproline

Norleucine

Proline

Serine

Tyrosine

The criterion for this classification is the ability of \
the body to synthesize certain of these substances. If
an amino-acid cannot be synthesized by the body, it is
called essential because it must be supplied from food.
Its absence from the diet will interfere with some essen-
tial body function such as growth or a positive nitrogen
balance. W. C. Rose made the original studies on rats
but others found that the same amino-acids were essen-
tial to dogs for continued growth and good health.
These essential amino-acids have been found to meet
human requirements. Protein foods are valuable in pro-
portion to the number of the essential amino-acids they
contain. Those of animal origin are of more value
because they are "complete” or contain all of the ten
essential amino-acids. All of the essential amino-acids
can be obtained from a mixed vegetable diet but no one
vegetable seems to contain all of them.

Not only are the body proteins synthesized from the
amino-acids, but the hormones and enzymes are also of
protein origin. As an example, the thyroid hormone,
thyroxin, is derived from diiodotyrosine which in turn
is derived from tyrosine. The analysis of crystalline in-
sulin shows that the molecule is composed of 88 per
cent of amino-acids. There is also the question of the
vitamins which seem to act as bio-catalytic agents in the
formation of both proteins and enzymes. Some of these
problems are slowly being solved. The fundamental
problems of the specific functions of each of the essen-
tial amino-acids must first be solved.

One of the important functions of the liver is to de-
toxify certain poisons. It has long been known that
chloroform anesthesia is followed by necrosis of liver
cells and that death can follow if this destruction is
great enough. Miller and Whipple 6 found that dogs

October, 1946

321

withstood chloroform anesthesia in proportion to the
proteinemia present. They showed that as protein stores
were depleted by a low protein diet, or by plasmapheresis,
the dogs were able to withstand less and less of the anes-
thetic. A normal well-fed dog can stand one hour of
chloroform anesthesia without showing any ill effects,
but a protein depleted dog will die in two or three days
following only twenty minutes of anesthetic. Protein
depleted dogs which were fed a protein meal but a few
hours before anesthesia were protected from liver dam-
age. Messinger and Hawkins 7 investigated the question
of the effect of diet and arsphenamine liver damage in
dogs. They found that dogs could withstand large doses
of the arsenical without liver damage if the protein
1 stores were high.

Miller, Ross, and Whipple *’ showed quite conclusively
) that methionine and cystine were the specific amino-
acids that protected the liver against chloroform damage.
This was proven by giving a variety of combinations of
the various amino-acids to hypo-proteinemic dogs and
subjecting them to varying periods of chloroform anes-
thesia. Their conclusions were: (1) Methionine and, to
a less extent, cystine given by mouth or vein twenty-four
to five hours before anesthesia, give a remarkable and
almost complete protection to the protein-depleted dog
against chloroform poisoning. (2) Other non-sulphur-
containing amino-acids alone, or in various combina-
tions as tested, convey no protection against chloroform
poisoning in similar experiments. (3) The protein-
depleted dog will succumb to fifteen to twenty minutes
light chloroform anesthesia and show extensive liver
necrosis. The dog protected by methionine will tolerate
forty minutes chloroform anesthesia with little or no
clinical disturbance and no evidence of liver injury.

They 6 suggest that the sulphydryl groups combine
with chloroform. This combination may inactivate en-
zyme systems and thus bring about cell death unless
there is an adequate reserve of cystine and methionine.

Here is definite evidence of the specificity of certain
of the amino-acids and liver functions. It also brings up
I the interesting relationship of sulphur and its importance
to various functions of the body. When we consider the
sulphur compounds which have become so important in
therapeutics in the last few years, such as the thio-
cyanates, thiouracil, and sulfonamides, it would seem
that we know very little of the part played by the vari-
ous body minerals in metabolism. According to Eddy,8
the manner in which methionine protects the animal
against liver damage is not clear but there is evidence
to support the belief that its value depends primarily
on the sulphur content of the amino-acids.

The antitoxic function of the liver seems to depend
on, or be greatly enhanced by, methionine and, to a lesser
extent, by cystine. This has been made use of clinically
and there are a number of reports in the last year where
the specificity of methionine seems to have been proven.
Eddy reports a number of cases of both TNT and car-
bon tetra-chloride poisoning with toxic hepatitis which
recovered by treatment with methionine. He also reports
a few cases of infectious hepatitis which seemed to re-
cover quickly. He gave doses of 6 to 8 grams daily and

reported no toxic reactions. A report by Wilson, Pol-
lack and Harris 9 on a group of British soldiers with
infectious hepatitis did not show this improvement. They
did not, however, use as large doses. Hoagland et al.
report 200 cases of infectious hepatitis which were di-
vided into groups, some being treated with methionine,
some with choline hydrochloride, some with liver extract,
and some as controls. They could see little difference
between these groups but they were all on a high pro-
tein diet. Beams 11 has recently reported a series of
cases of cirrhosis treated by choline and cystine with a
high protein diet and Brewers yeast. He seems to think
that the fatty changes in the liver were favorably
effected. The above cited work has shown the specificity
of but two of the essential amino-acids. The other essen-
tial amino-acids have not yet been worked out.

When we consider that plasma proteins are synthesized
in the liver, it is well to look at some of the problems
involved when their balance is upset by disturbances of
liver function. Water balance is maintained between
tissue cells and the circulating blood by osmosis. The
colloid osmotic pressure exerted by the plasma proteins
is the principal intravascular factor for maintaining the
blood volume. If hypoproteinemia is present, this col-
loid osmotic pressure is reduced by an escape of fluid
through the capillary walls and a reduction in blood
volume. This condition in itself can cause a reduction
in blood pressure, an increased load on the heart, and
can contribute to anoxia. Reduction in globulin, espe-
cially in the Gamma fraction, can materially effect the
patient’s ability to withstand infection.17 Reduction in
the fibrinogen and the prothrombin can profoundly
affect the clotting power of the blood. Reduction of the
albumens and the other protein constituents in the
plasma can affect all tissues in the body.

The causes of hypoproteinemia may be divided into
three classes: pre-hepatic, hepatic, and post-hepatic. The
latter two are directly related to hepatic function. The
pre-hepatic cause of protein deficiencies is due to inade-
quate supplies of amino-acids reaching the liver. This
may be due to many factors. Among them might be
mentioned excessive vomiting, diarrhea, anorexia from
any cause, indigestion (the patient is afraid to eat be-
cause of pain, as in gastric and duodenal ulcers) , and
carcinoma of the gastro-intestinal tract. Also, elimina-
tion diets in some allergic conditions and poorly bal-
anced diabetic diets may be a cause. A high metabolic
rate from thyrotoxicosis or fever may produce hypo-
proteinemia because of an increased need for carbohy-
drates which may be supplied by the de-amination of
amino-acids otherwise used to synthesize proteins. Prob-
ably the most common cause of hypoproteinemia is in-
adequate intake.

The direct hepatic causes of hypoproteinemia are re-
lated to impaired liver function. This may be the result
of toxins lowering the functional capacity of the liver
cells, from exhaustion of the liver cells from an increased
demand for protein synthesis, or from disease of the liver
itself which causes destruction of the liver cells. The
liver has enormous powers to regenerate new tissue and
in the presence of adequate supplies of amino-acids it

322

The Journal-Lancet

has been shown that the functional capacity of the liver
can be materially increased.10 A low protein diet will
produce liver damage which can materially interfere with
liver function.11 Here we have a vicious cycle in which
liver function is retarded by low intake and the resulting
hypoproteinemia results in further liver damage.

The post-hepatic causes of hypoproteinemia are due
to excessive losses of nitrogenous materials which may
result from repeated hemorrhages, drainage from large
abscesses, seepage from burned areas or any other source
of loss of plasma proteins. Some forms of nephritis can
be the cause of excessive loss of albumen. Trauma may
cause hypoproteinemia by increasing endothelial permea-
bility and tissue protein breakdown.14 Surgical pro-
cedures of all types, as well as general anesthesia, have
a measurable effect on the plasma proteins. Trauma and
hemorrhage incident to major surgical operations can
cause sufficient loss of plasma proteins to jeopardize the
life of a patient already hypoproteinemic.1'’

Since hypoproteinemia is so intimately connected with
liver function as well as with food intake, let us consider
some of the diagnostic measures which can give us some
information about it. Clinically, the patient may show
signs of malnutrition and weight loss. Many laboratory
tests have been developed to estimate various phases of
liver function, but few of these have proven exact and
then only for some one phase. The estimation of the
plasma proteins is reliable as to the amount of protein
present and may be used as direct evidence of the de-
gree to which the liver is able to synthesize protein. De-
hydration of the patient with a consequent concentration
of all blood elements can give quite normal findings in
the presence of hypoproteinemia and should be taken
into account. Normal plasma proteins average about
7 grams per 100 cc.10 As this figure approaches 5,
nutritional edema may ensue because of the reduction
in intravascular osmotic pressure.1'1 Another valuable
test to determine liver function indirectly is bleeding
time, which gives an estimate of the prothrombin pres-
ent. If this is altered, it probably means a lowering of
all plasma proteins.'1 It has been advocated that an
accurate estimation of liver function can be found by
measuring the prothrombin response to vitamin K.18
This has been found to be quite accurate. The clinical
estimation of the patient’s state of nutrition can be an
extremely useful guide as to the presence or absence of
hypoproteinemia. One that is losing weight, or has re-
cently lost weight, from whatever cause, should be sus-
pected of having low plasma proteins and probably will
prove to be a poor surgical risk.

When hypoproteinemia is present, the obvious remedy
is to administer an adequate supply of amino-acids both
to restore as much liver function as possible and to cut
down the destruction of tissue proteins. Obviously, saline
solution intravenously, with or without glucose, can be
of little help. The use of normal salt solution in a pa-
tient with low intravascular osmotic pressure may hasten
edema. The use of glucose is more rational as it supplies
an immediate source of energy and spares the liver from
having to deaminate protein substances to obtain glyco-
gen. However, from both experimental and clinical evi-

dence, amino-acids are needed to protect the liver from
damage and to give it material with which to synthesize
proteins for both plasma and tissues. Varco,1'’ in a re-
cent comprehensive article on diet, severely condemns the
giving of glucose with the idea of protecting the liver.

Hypoproteinemia can be corrected, whether it is due
to impaired liver function or inadequate intake of pro-
teins. A high protein diet may be very successful if
alimentation is reasonably normal. A variety of proteins
should be given to assure getting all of the essential
amino-acids. Varco has developed liquid diets composed
of high protein, high carbohydrate, and low fat which
make it possible to give 6,000 to 7,000 calories per day
for two weeks without disturbances. He depends on
skim milk powder to maintain a high protein content.
Such a diet contains all of the essential amino-acids and
minerals necessary and, with the addition of some vita-
mins, seems to be complete. If alimentation is impossible,
or in an emergency, the transfusion of blood or plasma
may be used. However, the effect is transient and has
to be repeated often, and means a prohibitive cost to
the patient. Recently, protein digests have been devel-
oped containing all of the essential amino-acids in solu-
tion which can be safely used intravenously if neces-
sary.1" These solutions seem to be as safe to use as
blood transfusions, as far as reactions are concerned.
Their application, based on both experimental and clin-
ical evidence, seems to be rational if we wish to restore
liver function as much as possible and build up the tissue
proteins from the natural constituents.

Summary

I have tried to show the intimate connection between
the functions of the liver and the diet as far as the pa-
tient’s wellbeing is concerned. As for reasoning from the
surgical standpoint, this modern method seems to make
sense. It has been interesting to watch the various phases
of surgical preparation of the patient which have been
used the last twenty-five years. We were then just
emerging from the era in which the patient was starved
and purged for two or three days before some planned
surgical procedure. Purging was at that time being
frowned on by some, but starvation was still considered
good practice. Then the "saline and glucose intra-
venously” enthusiasts had their day. This gradually
led to the use of blood transfusions for everything.
We are now slowly accepting the idea that food is
essential, protein food especially, to give the liver a
chance to best utilize its many functions.20

References

1. Wright, P.: Applied Physiology, 482. 1935.

2. Drew, H. O.: Sex Hormones and Their Relationships.
Journ. Lancet, LXIV:35, 1944.

3. Greene, C. H.: Liver and Biliary Tract. Arch. Int.

Med., 69: 691 (April), 1942.

4. Proteins and Amino-Acids. Arlington Chemical Co.
1944.

5. Protein Nutrition in Health and Disease. Council on
Foods and Nutrition, A.M.A. 1945.

6. Miller, L. L., and Whipple, G. H.: Chloroform Liver
Injury Increases as Protein Stores Decrease. Am. J. Med. Sc.,
199: 204, 1940.

7. Messinger, W. J., and Hawkins, W. B.: Arsphenamine

October, 1946

323

Liver Injury Modified by Diet. Am. J. Med. Sc., 199: 216,
1940.

8. Eddy, J. H.: Methionine in Treatment Toxic Hepati-

tis. Am. J. Med. Sc., 210: 216, 1940.

9. Therapeutic Trial of Methionine in Infectious Hepatitis.
Br. Med. J., 1: 139 (March), 1945.

10. Hoagland, C. L., and Shank, R. E.: Infectious Hepa-
titis. J.A.M.A, 130:615 (March 9), 1946.

11. Beams, A. J.: Cirrhosis of Liver. J.A.M.A., 130: 190
(Jan. 26), 1946.

12. Blood Fractionation; Symposium. Int. Med. Digest,
45: 181 (Sept.), 1944.

13. Handler, P., and Dubin, I. N.: The Significance of
Fatty Infiltration in Development of Hepatic Cirrhosis Due to
Choline Deficiency. Jour. Nutrition, 31: 141, 1946.

14. Abbott, W. E., Hirshfield, J. W., et al.: Metabolic Al-

terations Following Thermal Burns. Surg., Gyn. & Obstet,
81: 25, 1945.

15. Varco, R. L.: Preoperative Dietary Management for

Surgical Patients. Surgery, 19:303 (March), 1946.

16. Gottardo, P., and Winters, W. L.: Portal Cirrhosis.

Am. J. Med. Sc., 204: 205 (Aug.), 1942.

17. Sweet, N. J., Lucia, S. P., and Aggeler, P. M.: Clinico-
pathological Correlation Between Hepatic Damage and the
Plasma Prothrombin Concentration. Am. J. Med. Sc., 203: 665,
1942.

18. Vitamin K and Liver Function. (Edit.) Int. Med. Di-
gest, 40:251 (April), 1942.

19. Davis, H. H.: Routine Use of Protein Digest Intra-

venously Following Major Surgical Procedures. Surg., Gyn.
& Obstet., 81: 31, 1945.

20. Diet and Liver Injury. (Edit.) Lancet (London), p. 274,
(Feb. 23), 1946.

Anesthesia in General Practice

Ralph T. Knight, B.A., M.D., F.A.C.S.*
Minneapolis, Minnesota

There can be two interpretations of the subject of
anesthesia in general practice, both of which I shall
endeavor to touch upon. The first might be restated in
this way: "Anesthesia as a Part of General Practice.”
A general practitioner may be a skilled obstetrician, and
skilled in the diagnosis and treatment of the pneumonias,
the blood discrasias and diabetes, and many surgical con-
ditions. Why may he not be a skillful anesthetist? The
fact is that he may, in many communities he is. In these
communities he has largely solved the anesthesia prob-
lem by providing good anesthesia for his own and his
colleagues’ patients. He should be given every encour-
agement in participating in this worth-while activity.
Perhaps in most communities the general practitioner has
shunned anesthesia on three counts: He considers it a
nurse’s job; he considers it a nuisance; or he considers
himself unqualified. This is everybody’s fault, and must
be corrected.

The general practitioner is needed in anesthesia. He
himself has been so busy that he has depended upon
the nurse, with or without training, to give whatever
anesthetic she could. Nurses with anesthesia training are
now practically unavailable for smaller hospitals. The
large hospitals are now unable to get as many nurse anes-
thetists as they want. Great advances have been made
in the quality of anesthesia. In many centers the opera-
tive morbidity and mortality, and surgical recovery have
been improved beyond dreams of a few years ago, largely
by new and better anesthesia. To spread this into all
communities will require the active interest and participa-
tion of hundreds and thousands of doctors. Many new
medical graduates will decide to enter anesthesiology as
a specialty, and many more will make it an integral part
of their general practice.

As to considering it a nuisance, this has two phases,
economic and professional. Anesthesia may be done as
a dull routine which arouses little interest or skill. Due

Presented at the annual meeting of the North Dakota State
Medical Association, May 26-28, 1946.

*Clinical Professor and Director, Division of Anesthesiology,
University of Minnesota.

to underestimation, and routine assignment of the job
to an unskilled helper, the doctor usually classifies anes-
thesia as an underpaid chore. However, when doctors
are fully aware of the value to their patients of well con-
ducted anesthesia, when they provide it for them, and
explain its value, people pay equitably for it as for other
medical services and the economic part of the nuisance
does not exist.

As to the qualification of the general practitioner for
conducting anesthesia, the rapid change, advancement
and apparent complexity of anesthesia in the last ten
and more years as it has been developed in university
hospitals, and the crowding of time by other enlarging
subjects, has made it seem impossible to give medical
students and interns any real practical experience in
anesthesia. At the University of Minnesota we are
greatly expanding our numbers of graduate students in
anesthesiology fellowships who are preparing for certifi-
cation by the American Board. Within a few months,
when the entire service is covered by these graduate
students and they have gained experience, we will be able
to assign medical students and interns to them to par-
ticipate in the administration of anesthetics. More than
that, we hope also to be able to accept practitioners for
periods of three months or longer so that they can
become acquainted with all of the present procedures
in anesthesiology. We shall continue to offer continua-
tion courses of a week duration. These have drawn an
attendance of about fifty and will continue to increase.
Thus, new medical graduates will have more interest
and knowledge in anesthesia, and general practitioners
will have the opportunity to become proficient in the
field.

The second interpretation of this subject may be re-
stated in this way: "Anesthesia for the Needs of Gen-
eral Practice.” How shall a man manage the anesthesia
for his surgery in general practice? If he has a col-
league nearby who is interested and skilled, and who
has enough special equipment for a few efficient varia-
tions in anesthesia, the problem is solved. The patient
in such a community is fortunate.

324

The Journal-Lancet

Let us consider some questions which arise in carrying
on anesthesia with the help of a nurse who has, or has
not had, anesthesia training. A few salient points should
be stressed.

The ideal in each case is to have a free choice of
anesthesia with any drug and any variation of tech-
nique, of intravenous or inhalation anesthesia with the
best of equipment and complete assortment of gases
and liquids, and to use them separately, or in any com-
bination desired. If one has not had sufficient training
in the use of anesthetic gases, semi-open drop ether is
the best general anesthetic. Proper premedication must
always precede it. The patient must be quiet, at least a
little drowsy, and saliva and mucus must be under con-
trol. In children, from 1/40 grain to 1/8 grain of mor-
phine with 1/800 to 1/150 of atropine, or 1/1000 to
1/200 of scopolamine; in adults, from 1/8 to 1/4 grain
of morphine with 1/200 to 1/150 of atropine or scopo-
lamine, according to the size and vigor of the patient.
In emergencies, the premedication is even more impor-
tant and, if there is not at least a 3/4 hour lapse between
premedication and anesthesia, it should be given intra-
venously very slowly in 2 or 3 cc. of water over a period
of at least two minutes.

Induction can be made much more pleasant for both
children and adults by starting with vinyl ether until
unconsciousness arrives. A small fluff is best for the
vinyl ether. The ether mask is superimposed over this.
The ether must then be added very rapidly. The patient
will tend to awaken from the vinyl ether, thus a little
of this must be added on the mask from time to time,
while pouring on the ether rapidly until the anesthesia
is sufficient and stabilized. Induction may be quickly and
pleasantly accomplished also with sodium pentothal, 254
per cent, slowly injected intravenously until unconscious-
ness arrives. The ether must then be given cautiously
at first to avoid laryngospasm, which is rather encour-
aged by pentothal. The needle should be kept in the
vein for a while so that small amounts may be added
if necessary before the ether has full effect. With these
two agents available, vinyl ether and sodium pentothal,
one is hardly justified in subjecting a patient to the pro-
longed and distressing induction with ether alone.

Vinyl ether alone is a wonderful anesthetic for very
short procedures such as myringotomy, incision of boils,
etc., but is unsatisfactory for maintaining smooth anes-
thesia for longer procedures.

Much should be said about sodium pentothal. It is
the most perfect hypnotic we have ever had. The in-
duction and the awakening are so pleasant that it has
achieved tremendous popularity, both among the laity
and among the profession. It has achieved far too much
popularity, because its hypnotic quality is almost its only
good point. It does not stop pain stimuli or depress re-
flex activity with any efficiency. Surgeons are apt to
use it, with or without the request of the patient, because
of its pleasantness. In order to achieve quietness in the
presence of severe stimulation, very large doses are ad-
ministered, with the result that the patient’s brain and
medulla are greatly overdepressed. Pentothal should be
used freely for inductions and for short operations which

are not greatly stimulating. It is very satisfactory for
dilatation and curettage if one avoids skin clips, for
cystoscopy, and for reducing most fractures. It is not
satisfactory for operations upon the skin because these
are so stimulating that the surgeon is apt to require large
doses. Sodium pentothal is excellent in maintaining light
unconsciousness during local or spinal anesthesia. Most
of us believe that it should not be used for any purpose
in higher than 254 per cent solution. This avoids phle-
bitis and makes the anesthesia more accurate and con-
trollable. Sodium pentothal should be accompanied rou-
tinely whenever possible by Nl.O and CL. The best
combination is 500 cc. per min. each. This yields ap-
proximately 30 per cent oxygen.

The greatest boon to general anesthesia has been the
advent of curare. By the careful administration of
curare in the form of Intocostrin*, relaxation can be
achieved while administering only moderate or light doses
of general anesthetic. It is no longer necessary to pro-
duce deep anesthesia with ether, chloroform, sodium pen-
tothal or any other agent. The necessary dose of Into-
costrin depends directly upon the muscular vigor of the
patient and inversely upon the depth of general anes-
thesia which is already present. It is best not to decide
immediately on the dose, but to keep the needle in the
vein, inject 20 or 30 units to begin with, and add 10 or
20 units at a time at intervals of 45 seconds until the
desired relaxation is obtained.

During the last year, I have been working with the
combination of sodium pentothal and curare in fixed
ratios accompanied by light nitrous oxide anesthesia.
This is very promising for all types of surgery and I
have hopes that it may prove to be the best all-around
type of anesthesia for most types of surgery in general
practice, if used with proper precautions. I am not yet
quite ready to advocate it in this way.

In the absence of a skilled anesthetist, the surgeon in
general practice has leaned very heavily upon spinal
anesthesia. This is certainly justifiable if all of the proper
precautions are taken. However, there has been a tend-
ency to use it ad lib with no more equipment or prepa-
ration than a spinal needle, a syringe and an ampule of
anesthetic. Any man who administers a spinal anesthetic
should look upon it as a major procedure, worthy of
the most careful thought and management of all details.
He should become well acquainted with one or two drugs
and use them consistently without too much variation in
technique. Procaine and pontocaine should probably be
the first two in anyone’s repertoire. Procaine should
never be injected in stronger solution than 5 per cent
as it leaves the syringe. Pontocaine should never be in-
jected in stronger solution than 0.5 per cent as it leaves
the syringe.

Procaine is always heavier than spinal fluid and will
tend to gravitate downward. The head of the table may
be lowered slightly after injection until anesthesia reaches
the level desired. Trendelenburg position should never be
employed sooner than 10 or 15 minutes after injection.

Pontocaine is best used in the crystalline form, called

* E. R. Squibb and Sons.

October, 1946

325

niphanoid. It is then dissolved in spinal fluid and the
result is always slightly heavier than the patient’s spinal
fluid. It does not spread readily from the site of injec-
tion and needs to be encouraged by tilting the head of
the table downward until the desired level is reached.
Pontocaine has the reputation of being responsible for
more failures in anesthesia than any other anesthetic.
The reason for this is that it does not spread readily
and therefore the height of anesthesia is apt to be lower
than expected. If one realizes this, he can take the
proper measures by using a higher interspace, and also
by tilting the table and waiting sufficient time until the
anesthesia is high enough. Pontocaine which comes in
a solution form has a specific gravity almost exactly
equal to average spinal fluid, but spinal fluids differ con-
siderably and therefore one never knows whether the
solution is lighter or heavier than the spinal fluid in the
case at hand. It is much better if this solution is being
used, to keep with it 3 cc. ampules of 10 per cent dex-
trose and dilute the solution with an equal amount of
the dextrose before injecting it. This results in 0.5 per
cent pontocaine and 5 per cent dextrose, which is always
heavier than spinal fluid. One knows then definitely how
to manage.

The salient point to be stressed in giving any kind of
anesthesia in general practice is the need of taking nec-
essary precautions for the patient’s welfare. Certainly
no anesthetic should be given in a hospital without hav-
ing at hand a cylinder of oxygen attached to a well-

fitting mask and a breathing bag. This is minimum
equipment. No anesthesia is trivial enough to be given
without this at hand. This simple equipment will suffice
for an emergency but an anesthesia machine is to be pre-
ferred. Whenever there is the slightest doubt during
general, spinal, or local anesthesia as to whether the pa-
tient is breathing freely and correctly, or as to whether
the patient’s color and pulse are good, the mask should
be applied snugly and the respiration should be helped
by synchronous pressure upon the breathing bag. This
procedure should become commonplace wherever anes-
thetics are administered and should never be postponed
until the condition of the patient causes concern. Even
for an anesthesia given in a home, the physician would
do well to carry this extra equipment with him.

The patency of the patient’s airway should never be
taken for granted. Rubber artificial airways should be
used freely during any general anesthesia in addition to
holding the jaw forward. One must never be satisfied
for a minute unless the breathing is perfectly free and
practically noiseless.

In conclusion, the most important procedure, in my
opinion the simplest, is that after an anesthesia the pa-
tient must be turned upon his side and remain so upon
the litter and in bed until he is thoroughly recovered.
There is no inconvenience important enough to forestall
this maneuver for even a short time. Many lives have
been lost, and many cases of pneumonia and lung ab-
scess have been caused by neglect of this simple measure.

SUBACUTE BACTERIAL ENDOCARDITIS

A significant proportion of patients acquire bacterial endocarditis as a result of dental
procedures, especially extraction of a tooth. For this reason, all patients who have valvular
heart disease, either rheumatic or congenital, should be warned that they must never have any
dental operation performed except under conditions where adequate prophylactic measures can
be instituted. What constitutes a satisfactory prophylactic regimen has not yet been clarified.
One patient developed the disease after tooth extraction in spite of full doses of sulfadiazine
plus 25,000 units of penicillin every three hours for two days. At present Dr. Thos. H.
Hunter, New York City, gives sulfadiazine plus 100,000 units of penicillin every three hours
for forty-eight hours followed by several days of sulfadiazine alone. Whether or not this will
prove adequate remains to be seen.

It may be said that subacute bacterial endocarditis is a disease fundamentally amenable to
cure by chemotherapy and that penicillin has proved the most satisfactory agent so far. Be-
cause of the varying sensitivity to penicillin of different strains of nonhemolytic streptococci,
it is strongly recommended that the sensitivity of the organism be determined in each individual
case. The dosage necessary to effect cure of the disease varies widely from case to case depend-
ing primarily on the susceptibility of the infecting strain. With intensive and persistent ther-
apy, it is possible to cure the infection in almost every patient, although at times as much as
20,000,000 units a day may be required. — From Modern Concepts of Cardiovascular Disease,
August 1946.

326

The Journal-Lancet

Thiouracil in the Management of Hyperthyroidism

Richard L. Egan, M.D.*

Omaha, Nebraska

Thiouracil, a drug without known therapeutic ap-
plication five years ago, and possessing a specific
action on the thyroid gland, has recently been released
for general use. It is the first major change in the man-
agement of hyperthyroidism since Plummer 1 introduced
iodine as a preoperative measure in 1923. Already there
is much difference of opinion regarding its usefulness.

Certain points in the history of hyperthyroidism give
perspective to an evaluation of thiouracil. In 1913 Plum-
mer 2 described the cyclic nature of exophthalmic goiter
and noted its tendency to spontaneous remission and
exacerbation. An excessive mortality resulted from sur-
gical therapy until the introduction into general use of
iodine solution as a preoperative measure. Good surgical
treatment is now conceded to be so satisfactory that any
innovation must bear the burden of proof.

Iodine followed by surgery is not however without
several disadvantages. Surgery is attended with an un-
avoidable anesthetic and operative risk. Iodine does not
reduce the basal metabolic rate to normal. When max-
imal response to iodine has occurred the disease may
escape from its control and then be refractory to further
benefit. In spite of careful management, postoperative
crises are not unknown. After surgery either myxedema
or recurrence of hyperthyroidism may result.

The recognition of the antithyroid properties of sev-
eral drugs was the result of several independent investi-
gations. Kennedy,3 studying various constituents of
Brassica seed, noted that thiourea depressed the metab-
olism of rats. He observed that this action was accom-
panied by enlargement of the thyroid gland. MacKenzie
et ah, 4 while investigating sulfaguanidine, noted a de-
pression of the metabolism of rats fed this substance.
Because of the thyroid hypertrophy and hyperplasia
resulting from these compounds, they were termed goitro-
genic. A great number of aniline derivatives, including
the sulfonamides, have a potential goitrogenic action,
as have thiourea derivatives such as thiouracil. Astwood 0
has studied many of them and concluded that thiouracil
is the most potent and least toxic of these depressants of
thyroid secretion.

These investigations have added to our practical
knowledge of hyperthyroidism. They have shown that
an intact pituitary is essential for the thyroid hypertro-
phy accompanying the use of goitrogenic drugs. The
action of desiccated thyroid is not inhibited by the simul-
taneous administration of a goitrogenic compound. The
desiccated thyroid does prevent the hypertrophy of the
animals’ thyroid gland, probably by inhibiting the forma-
tion by the pituitary of thyrotropic hormone. This pitui-
tary activity may be an important factor in the develop-

An abridgement of a paper presented at a meeting of the
Yankton District Medical Society at Vermillion, South Dakota,
April 23, 1946.

*From the Department of Medicine, The Creighton Univer-
sity School of Medicine, Omaha, Nebraska.

ment of exophthalmos and glandular hypertrophy in
human exophthalmic goiter. It seems established that
thiouracil reduces metabolism by interference with the
formation by the thyroid of its secretion.

After oral administration thiouracil is rapidly absorbed.

It is slowly eliminated in the urine. It is also eliminated
in the milk. Some may be destroyed in the body. It is
to be found in all tissues of the body, but the blood
cells contain more than the plasma; the leucocytes con-
tain more of the drug than the erythrocytes.'1

Since the first reported use of thiouracil in human
hyperthyroidism,' there has been but one absolute indi- j
cation — hyperthyroidism occurring in individuals for j
whom a surgical operation is absolutely contraindicated.

In the human, thiouracil is capable of reducing the
basal metabolic rate to normal. Objective evidence of
improvement usually precedes the fall in the basal meta- j
bolic rate. As long as it is continued in sufficient amount,
there is no escape from its action. The response of the
patient may be delayed if iodine has previously been
administered. It is slower in action when given to cases
of toxic nodular goiter than when used for the control
of exophthalmic goiter.

After a brief period of hospitalization, our patients
returned to their homes and to their work. They have
returned to the out-patient department at weekly inter-
vals for examination, basal metabolic rate determination,
and white blood count. We have found that the basal
metabolic rate, when determined on out-patients, is only
a general indication of the patient’s progress. s

The abnormal chemistry of hyperthyroidism is cor-
rected by thiouracil.9 The nitrogen, calcium and phos-
phorus balance become positive. With the reduction of
the metabolic rate there is a lessening of the emotional
instability, a gain in strength and weight, and a return
to normal of the pulse rate.

Thiouracil is used in amounts of 0.4 to 0.6 grams
per day in divided doses until the hyperthyroidism is
controlled. At present, the lesser amount is preferred. ;
A maintenance dose, determined by trial and error, of
0.05 to 0.2 grams per day is continued until surgery •
or until a spontaneous remission of the disease occurs.

Thiouracil usually does not diminish the exophthalmos
associated with most cases of exophthalmic goiter. Our
experience with the use of desiccated thyroid to control
exophthalmos has not been favorable. Palmer,10 with
a larger experience, has, however, found it of value.

As a preoperative measure, thiouracil has now become
well established. Lahey 11 has written to the effect that
thiouracil is an essential for the correct preoperative
preparation of the patient with severe thyrotoxicosis.

Its success was at one time threatened by reports of
dangerous vascularity of the thyroid gland at the time
of surgery. This is obviated if iodine is administered
after the hyperthyroidism is controlled and before sur-
gery is attempted.

October, 1946

32 7

As a substitute for surgery, thiouracil is as yet too
; new for complete evaluation. We continue to advise
surgery, after preparation with thiouracil, in cases of
toxic nodular goiter because of the possibility of malig-
nancy. Our only exception has been in case other dis-
ease makes surgery exceptionally hazardous. We also
advise surgery if circumstances preclude adequate and
prolonged observation of the patient receiving thiouracil.

We do not know how long the diffuse toxic goiter
must be controlled with thiouracil before a prolonged
remission may be expected. One of our patients, against
our advice, discontinued treatment after two months of
j thiouracil therapy. Her symptoms returned after remain-
ing well for about two months. The available litera-
ture 12,13 indicates that relapse after discontinuing thio-
uracil is the rule if treatment is of only a few months’
duration. If treatment is of a longer duration, there is
an increase in the number of prolonged remissions.
These series are as yet too small to permit the statement
; of an ideal regime. We continue the drug for at least
one year.

As a substitute for surgery, the dangers of thiouracil
must be evaluated against the hazard of operation. In-
formation regarding the dangers encountered in nearly
7,000 cases receiving thiouracil is available.14,1'' The
most serious reaction is agranulocytosis which may be
expected to occur once in 50 cases, and prove fatal once
in 200 cases. It is most prone to occur during the first
eight weeks of treatment. Frequent leucocyte determina-
tions and the instruction of the patient to promptly
report any indisposition is the best means to prevent its
occurrence. Inability to secure this degree of patient co-
operation, we believe, contraindicates the use of thio-
uracil. Other less serious reactions may necessitate the
stopping of thiouracil therapy in as many as one out of
ten patients.

In conclusion, thiouracil is capable of reducing to nor-
mal the metabolic rate of the patient with hyperthyroid-

ism. As a preoperative measure it brings the safety of
a normal metabolism. As a substitute for surgery, it is
an effective palliation but as yet an unproven cure.
With either application the dangers of the drug, chiefly
agranulocytosis, must be judged against the dangers of
conventional therapy.

Bibliography

1. Plummer, H. S.: Results of Administering Iodin to

Patients Having Exophthalmic Goiter. J.A.M.A., 80: 1955,
1923.

2. Plummer, H. S : The Clinical and Pathological Rela-

tionship of Simple and Exophthalmic Goiter. Am. J. M. Sc.,
146: 790-795, 1913.

3. Kennedy, T. H.: Thioureas as Goitrogenic Substances.
Nature (London), 150:233, 1942, cited by Astwood, E. B.:
Treatment of Hyperthyroidism with Thiourea and Thiouracil,
J.A.M.A., 122: 78-81, 1943.

4. MacKenzie, J. B., MacKenzie, C. G., and McCollum,

E. V.: Effect of Sulfanilylguanidine on the Thyroid of the

Rat. Science, 94:518-519, 1941.

5. Astwood, E. B.: The Chemical Nature of Compounds
Which Inhibit the Function of the Thyroid Gland. J. Pharma-
col. & Exper. Therap., 78: 79-89, 1943.

6. Williams, R. H., Kay, G. A., and Jandorf, B. J.: Thio-
uracil, Its Absorption, Distribution and Excretion. J. Clin.
Invest. 23:613-627, 1944.

7. Astwood, E. B.: Treatment of Hyperthyroidism with

Thiourea and Thiouracil. J.A.M.A., 122: 78-81, 1943.

8. Sachs, A., and Egan, R. L.: Thiouracil in the Treatment
of Hyperthyroidism. Nebraska M. J., 30:431-434, 1945.

9. Sloan, M. H., and Shorr, E.: Metabolic Effects of Thio-
uracil in Graves’ Disease. Science, 99: 305-307, 1944.

10. Palmer, M. V.: Hyperthyroidism and Thiouracil, Ann.
Int. Med., 22: 335-364, 1945.

11. Lahey, F. H., Bartels, E. C., Warren, S., and Meissner,
W. A.: Thiouracil — Its Use in the Preoperative Treatment of
Severe Hyperthyroidism. Surg., Gynec. & Obstet., 81:425-
439, 1945.

12. Astwood, E. B.: Thiouracil Treatment in Hyperthyroid-
ism. J. Clin. Endocrinol., 4: 229-248, 1944.

13. Barr, D. P., and Schorr, E.: Observations on the Treat-
ment of Graves’ Disease with Thiouracil. Ann. Int. Med.,
23:754-778, 1945.

14. Moore, Francis D.: Toxic Manifestations of Thiouracil
Therapy, J.A.M.A., 130:315-319, 1946.

15. VanWinkle, W., Jr., et al.: The Clinical Toxicity of
Thiouracil. J.A.M.A., 130: 343-347, 1946.

EFFECT OF ALTITUDE ON CASES OF PNEUMOTHORAX

Travel by air has become so commonplace that it is easy to overlook the fact that thb
altitude to which commercial planes ascend constitutes a risk to individuals whose pulmonary
tubercuolsis is under treatment by means of pneumothorax. The recent report of the death,
during flight, of a patient under treatment by pneumothorax, sharply emphasizes this hazard. —
Tuberculosis Abstracts, October 1946.

HEALTH ASSURANCE

Health is not an inalienable right. It is a privilege. Privileges invariably entail equiva-
lent responsibilities. It is so easy to accept privileges that before long mankind takes them for
granted and claims them for inherent rights. Nature grants few rights, preferring to demand
that privileges be earned. Health, like freedom and peace, continues only as we exert our-
selves wisely to maintain it. — Edward J. Stieglitz, M.D., A Future for Preventive Medicine.

328

The Journal-Lancet

The Immunology of Poliomyelitis

Charles A. Evans, M.D.*

Seattle, Washington

Of the many voids in our knowledge of poliomyelitis,
those having to do with the immunology of this in-
fection are among the least clearly recognized by the med-
ical profession. It is not generally recognized, for exam-
ple, that there is real doubt as to the degree of immunity
that follows an attack of this disease. It is true that
second attacks of poliomyelitis are rare, but whether this
is the result of acquired immunity or of the chance dis-
tribution of a disease which strikes only a small propor-
tion of the population, is not clear. Fischer and Stiller-
man 1 in 1938 and Harmon and Harkins 2 in 1936 pre-
sented evidence that the attack rate for poliomyelitis
among persons who have had one attack of the disease
is as great as in those of the same age who have not
had a previous infection.

The tendency of poliomyelitis to attack persons in the
younger age groups is ordinarily ascribed to previous im-
munizing but unrecognized infections which most per-
sons are presumed to undergo before reaching maturity.
Evidence for this concept is the well known fact that the
serum of most normal adults will neutralize the polio-
myelitis virus. The inference is that persons whose serum
has the capacity to neutralize virus, are immune.

Yet, when specimens of serum of patients just coming
down with poliomyelitis have been tested, many were
found to possess the capacity to neutralize virus. Burnet
and Jackson '* found such antibodies in one-third of a
series of fifteen cases. These data do not support the
concept that the neutralizing antibodies found in some
persons’ serum are necessarily protective.

In fact, the possibility that physiologic changes asso-
ciated with growth and maturation are the basis for the
age distribution in poliomyelitis cannot be entirely dis-
counted. There is evidence that the physiologic status
alters susceptibility.4 The attack rate among pregnant
women is significantly greater than that among non-
pregnant women of the same age. Castrated female
monkeys are reported to be more susceptible to intra-
nasally administered poliomyelitis virus than normal
monkeys. Whether physiologic factors determine which
persons develop paralysis and which do not, has not been
determined.

An unusual feature of poliomyelitis is the frequent
absence of neutralizing antibodies in persons who have
recovered from the disease. It is known that an occa-
sional person who has had typhoid fever or brucellosis
may fail to develop significant amounts of agglutinins
to causative bacteria but in poliomyelitis this failure of
antibody response appears to be much more frequent
than in other infectious diseases. From reports in the
literature Harmon and Harkins 2 calculated that nearly
40 per cent of some 183 convalescent sera tested, were
without neutralizing antibody. It would seem that con-
valescent serum might be a poorer source of antibodies

*Department of Microbiology, University of Washington.

without neutralizing antibody. It would seem that conva-
lescent serum might be a poorer source of antibodies to
the poliomyelitis virus than pooled normal adult serum.

The possibility of developing a vaccine for poliomyeli-
tis virus has been investigated for many years and it has
been shown that an appreciable degree of immunity may
be conferred upon monkeys by injecting certain killed
virus preparations. Killed virus vaccines, in general, are
effective only if a rich source of virus is available. Thus,
vaccines for equine encephalomyelitis were not satisfac-
tory when made from the brains of horses. Only a low
degree of immunity could be achieved with preparations
from this source because the amount of virus in any rea-
sonable dose of vaccine was insufficient to induce a strong
antibody response. When it was discovered that virus
grew thousands of times more abundantly in chick em-
bryos than in horse brains, an active vaccine for equine
encephalomyelitis was readily prepared by treating infect-
ed chick embryo tissues with formalin to kill the virus.

In poliomyelitis, a rich source of virus has not been
readily available. Methods of purifying virus from ordi-
nary sources (monkey spinal cord, feces) may be em-
ployed but at present are too cumbersome to be of much
value. If an adequate source of virus is found, there will
still be the question of whether the virus is like the ty-
phoid bacillus in that it actively stimulates protective
antibodies, or like the brucellosis organisms with which
good protection has not been obtained by the injection
of killed organism.

It has been shown with plant viruses, with bacteriophage, and
finally with mammalian viruses that in some instances the pres-
ence of a relatively benign virus in a cell will prevent infection
with a highly virulent virus that is more or less related to the
first. This phenomenon is spoken of as cell-blockade or virus
interference. It is interesting to speculate on the possibility of
protecting humans from virulent poliomyelitis virus by admin-
istering a nonvirulent virus to produce a blockade of this sort.

In view of the widespread occurrence of harmless poliomyeli-
tis-like viruses in the intestinal tracts of mice,'1 one wonders
whether such a virus may be found in the human intestinal
tract. If so, it might be feasible to seed the human alimentary
canal or other portals of entry with an inoccuous virus of this
sort and block invasion of more virulent viruses by this portal.

Such developments are far in the realm of speculation at this
time. However, the fact that Green ® has demonstrated a thor-
oughly practical method of utilizing cell-blockade in protecting
foxes and dogs from virulent distemper virus, lends encourage-
ment to the exploration of possible fields of usefulness of this
phenomenon in the control of human diseases, such as polio-
myelitis. References

1. Fischer, A. E., and Stillerman, M. J.A.M.A., 1938,
110, 569.

2. Harmon, P. H., and Harkins, H. N. J.A.M.A., 1936,

107, 552.

3. Burnet, F. M., and Jackson, A. V. Aust. J. Exp. Biol,
and Med. Sci., 1939, 17, 261.

4. Data principally from papers of Draper and Aycock.
Summarized by Rivers, T. M., in Infantile Paralysis, a sym-
posium delivered at Vanderbilt University, April 1941. Pub-
lished by the National Foundation for Infantile Paralysis, Inc.
P. 63.

5. Theiler, M., Medicine, 1941, 20, 443.

6. Green, R. G., and Stulberg, C. S. Proc. Soc. Exp. Biol,
and Med., 1946, 61, 117.

October, 1946

329

American Student Health Association News-Letter and Digest of Medical News

Health in Colleges, a Third National Conference

Fifteen years ago the first Conference on College
Hygiene convened at Syracuse University. The printed
Proceedings of this Conference have since served as a
guide for the organization of college health programs.
In 1935 a Second Conference was held in Washington.
The attendance of several hundred represented leading
ideas in college health problems from diverse groups.
The revised Proceedings added to the relatively meager
library of specific information about the organization and
functions of college health services.

Now plans are well under way for a Third Confer-
ence. The need is greater than before. Existing health
services want guiding in the expansion of programs no
longer adequate for new health responsibilities; many
schools formerly having no organized programs are in-
terested in setting up new departments.

This Third National Conference on Health in Col-
leges is scheduled for the Hotel New Yorker, New
York City, May 7-10, 1947.

In the few months now remaining prior to the Con-
ference, preliminary work will be done by nineteen com-
mittees composed of five to ten members each, and
grouped into six sections covering the major aspects of
Health in Colleges. The Planning Committee is trying
diligently to build these committees from representative
geographic areas and from representative leaders in vari-
ous fields interested in health of young people.

Sponsorship of the Conference, soon to be announced,
is by organizations likewise deeply interested in Health
in Colleges. A leader in education, Alexander Ruthven,
President of the University of Michigan, has accepted
the presidency of the Conference.

This is your Conference. Mark the dates on your cal-
endar and plan on attending. If you are not working
on a committee, you will have opportunities to voice
your opinions. The best thinking and ideas of the entire
groups will constitute the Proceedings of the Third Na-
tional Conference on Health in Colleges.

Ralph I. Canuteson, M.D.,

President, A.S.H.A.

Physicians are Needed in the Following Colleges:

Stephens College, Columbia, Missouri.

Temple University, Philadelphia, Pennsylvania, Wil-
liam L. Hughes, M.D., Director.

Florida State College for Women, Tallahassee, Flor-
ida, President Doak S. Campbell.

Alabama Polytechnic Institute, Auburn, Alabama,
President L. N. Duncan.

University of Oregon, Eugene, Oregon. Fred N.
Miller, M.D., Director.

Applications for Membership in A.S.H.A.

1. Muhlenberg College, Allentown, Pennsylvania.

2. State Teachers College, LaCrosse, Wisconsin.

Personnel Changes

Robert Young, M.D., is leaving the Health Service at
Northwestern University on September 15th, to become
Dean of the Medical School at the University of Utah.

Leonard Folkers, M.D., has left Stephens College to
enter private practice.

Eva Strohan, M.D., has resigned from the Health
Service at Texas State Teachers College to go into pri-
vate practice. She has been succeeded by Bobby Short,

M.D.

Louis E. Hutto, formerly at Central Michigan Col-
lege, is in Salem, Massachusetts.

Almina Cameron, M.D., is succeeding Eleanor Nel-
son, M.D., at Mills College.

Steven E. Staryk, M.D., has joined the staff of the
Health Service at Wayne University. He graduated
from Wayne University Medical School in 1943.

Dr. R. C. Bull, who recently resigned from Lehigh
University because of ill health, is living at Delta, Colo-
rado. He can’t keep quiet. The Rotary, Boy Scouts
and lodge activities use some of his energies.

A total of approximately $50,000 in grants-in-aid to several American Universities for
cancer research has been approved by the U. S. Public Health Service, Federal Security
Agency, upon the recommendation of the National Advisory Council.

Included is $2,100 to the University of Minnesota to support a study of gastritis in rela-
tion to carcinoma of the stomach, under the direction of Dr. Robert Hibbel.

The committee on Gastric Cancer of the National Advisory Cancer Council is continu-
ing plans for an intensified study and program of attack on cancer of the gastro-intestinal
tract, which claimed the lives of about 80,000 Americans during 1945.

The National Advisory Cancer Council has recommended that Surgeon General Thomas
Parran call a conference on gastric cancer at the University of Chicago in the late fall of
1946. Gastric cancer has been receiving special attention from the Cancer Council since 1940
when it sponsored a conference on gastric cancer at the National Cancer Institute, attended
by leading scientists from universities and institutions throughout the country.

330

The Journal-Lancet

. . . EI1EET OUR C0I1TRIBUT0R8 . . .

Dr. Harry O. Drew was a contributor to the Oc-
tober 1945 issue of Journal-Lancet. Since then he
has been elected president of the Yellowstone Valley
Medical Society.

Dr. Ralph T. Knight contributed to the May 1946
issue of Journal-Lancet. He is at present diplomate
of the American Board of Anesthesiology.

Dr. Richard L. Egan is instructor in Medicine,
Creighton University School of Medicine, Omaha, Ne-
braska, and member of the attending staff of Creighton
Memorial St. Joseph’s Hospital. He is also a member
of the Omaha-Douglas County Medical Society, the
Nebraska State Medical Association, and the A.M.A.

Dr. Charles Evans was one of the five University of
Minnesota professors who were awarded grants by the
John and Mary Markle Foundation, New York City.
Dr. Evans was given three grants totaling $6,000 to
aid his study of virus infections of intraoscular tissues
and lymph nodes. He is now with the Department of
Microbiology, University of Washington, Seattle.

Book Reviews

Corky the Killer, A Story of Syphilis, by Harry A. Wil-
mer, M.D. New York: American Social Hygiene Associa-
tion, 1945. Pp. 67, illustrated. $1.00.

Dr. Wilmer’s first contribution to medical literature was
Huber the Tuber, a blend of fantasy and fact about tubercu-
losis designed for the lay public. In his new book he writes
in the same style about syphilis, the disease which Surgeon
General Parran has called our most urgent public health prob-
lem today.

The book puts forward the elementary facts about syphilis
by describing the adventures of Corky the Killer, who personi-
fies the Spirochaeta pallida. Corky and his fellow spirochetes
stealthily enter the body by submarine in the still of the night,
intent upon sabotage. Corky zips around the blood stream in
a corpuscle-motorboat, supervising the spirochetes as they set
about their deadly work. Operations are proceeding according
to schedule when the spirochetes are attacked by chemical blood-
hounds injected into the blood. After a fierce battle the blood-
hounds are victorious and Corky dies in the agonies of the
Soap and Water Treatment.

The author has reinforced his story with graphic and clever
full-page drawings of the spirochetes in action inside the body.
A more scientific discussion of the course and treatment of
syphilis accompanies the story about Corky.

The author emphasizes the seriousness of syphilis and the
importance of early treatment. Given wide circulation, the in-
formal and entertaining presentation can do much toward cre-
ating a healthy and intelligent public attitude about the disease.

A. A.

Oral Medicine, by Lester W. Burket, M.D., D.D.S. Phila-
delphia: J. B. Lippincott, 1946. Pp. 674, illustrated. $12.00.

This is a comprehensive, well organized, authoritative, and
practical book, dealing thoroughly and clearly with the many
relationships between oral and systemic diseases.

The special colored atlas of sixty plates illustrating oral lesions
most often encountered in a daily practice by the dentist and
physician is most valuable. The subject matter should prove
to be an asset to medical and dental students, and very helpful
as a reference book for the general practitioner. J. C.

Manual of Tuberculosis, Clinical and Administrative, by

E. Ashworth Underwood, M.D. 3d edition, revised and

enlarged. Baltimore: Williams and Wilkins Co., 1945.

Pp. 513, illustrated. $4.50.

The author, an Englishman, presents in a simple and sys-
tematic way all the varied forms of tuberculosis.

In this new edition, chapters have been added on the evolu-
tion of pulmonary tuberculosis; allergy and immunity as related
to tuberculosis; X-rays and radiography as applied to tubercu-
losis work; mental aspects of the disease; methods employed as
a routine in the clinical laboratory; social medicine and tuber-
culosis; and tuberculosis and war.

The social and administrative functions relevant to this dis-
ease are stressed in this manual inasmuch as they are a particu-
lar problem in England at present. The author states that a
quarter of a million people in that country are suffering from
tuberculosis in its active form.

This book will prove of value to all physicians in the field of
tuberculosis because it is thorough, comprehensive, and up-to-
date.

A Blind Hog’s Acorns, by Carey P. McCord, M. D. Chi-
cago and New York: Cloud, Inc., 1945. Pp. 311, illus-

trated. $2.75.

Dr. McCord’s "acorns” are vignettes about workers and their
diseases. The author has spent twenty-five years working as an
industrial hygienist and medical consultant to industry, investi-
gating occupational diseases and their causes. He has written
numerous technical brochures, but this is his first book in pop-
ular style.

Here he has recorded a number of his experiences in the haz-
ardous trades, writing in anecdotal style about various indi-
viduals and diseases he has run across. The author skips mer-
rily about through time and space as he relates his stories; in
a summary chapter he admits to a "shameless disregard for the
niceties of chronology” and organization. He tells about the
unusual and eccentric human beings he has encountered and of
how he has ferreted out the causes of mysterious maladies that
afflicted office and industrial workers. The book is a sort of
medical sideshow, a by-product of the career of a pioneer in
the field of industrial hygiene. A. A.

Women in Industry: Their Health and Efficiency, by
Anna M. Baetjer, Sc.D. Philadelphia: W. B. Saunders
Co., 1946. - -

This worth-while book was issued under the auspices of the
Division of Medical Sciences and the Division of Engineering
and Industrial Research of the National Research Council. The
data is graphic and scientific and represents an extensive sur-
vey on every phase of health and efficiency of women in rela-
tion to their employment. The author also stresses various
phases in this complex problem which need further investiga-
tion and thus offer a fruitful approach to preventive medicine
and public health. The manual is further enriched by the list-
ing of a substantial bibliography of both foreign and local
source, and a summary of state labor laws for women. The
physician and health worker will find in these pages the maxi-
mum of information to date on the subject.

Curare-Intocostrin: History, Pharmacology and Chemistry

of Curare; Clinical Uses of Intocostrin. Prepared and edited
by E. R. Squibb & Sons from more than 120 articles in
Journal-Lancet and other recent medical literature up to
and including the early months of 1946. 292 pp. For copies
write H. Sidney Newcomer, M.D., Squibb Bldg., 745 5th
Ave., New York 22-

A compendium of the literature of Intocostrin (the first
available physiologically assayed preparation made from a native
curare plant — chondodendron tomentosum) and its ever broad-
ening therapeutic role. Reports of 148 investigators and clin-
icians, arrange chronologically in chapters according to subject
matter. Clinical reports on the use of Intocostrin are to be
found under the classifications Anesthesia; Shock Therapy;
Spasticity, Rigidity and Tremor; Poliomyelitis; Endoscopy;
Tetanus Convulsions; and the Diagnosis of Myasthenia Gravis.
In addition, a detailed subject index and author index has been
provided.

October, 1946

331

Transactions of the Montana State
Medical Association

Sixty-Eighth Annual Session
Great Falls, Montana, July 18-20, 1946

OFFICERS, 1946-1947
(Elective)

M. A. SHILLINGTON, Glendive President

L. W. ALLARD, Billings President-Elect

C. H. FREDERICKSON, Missoula Vice President

H. T. CARAWAY, Billings Secretary-Treasurer

R. F. PETERSON, Butte Delegate to A.M.A.

T. L. HAWKINS, Helena Alternate Delegate to A.M.A.

EXECUTIVE COMMITTEE
J. C. SHIELDS Butte

L. W. ALLARD Btllings

H. T. CARAWAY Billmgs

S. A. COONEY Helena

M. A. SHILLINGTON Glend.ve

COUNCILORS

District I— G. W. SETZER Malta

District 2— C. W. LAWSON Havre

District 3 — J. H. GARBERSON Miles City

District 4 — T. R. VYE Laurel

District 5 — R. G. SCHERER Bozeman

District 6 — R. G. JOHNSON Harlowton

District 7— T. B. MOORE Kalispell

District 8— J. H. IRWIN Great Falls

District 9 — H. W. GREGG Butte

District 10 — A. C. KNIGHT Phillipsburg

District 1 1 — D. T. BERG Helena

District 12 — A. R. FOSS Missoula

APPOINTED COMMITTEES

(Committee appointments are all for one year unless
otherwise designated)

MEDICAL INSURANCE AND LEGAL AFFAIRS COMMITTEE

J. H. BRIDENBAUGH, Chairman Billings

W. F. CASHMORE Helena

W. E. LONG Anaconda

R. E. RYDE , Glasgow

R. TONEIL Roundup

MEDICAL PUBLICATIONS COMMITTEE

R. G. SCHERER, Chairman Bozeman

ELOISE M. LARSON Livingston

U. S. MEDICAL RESERVE COMMITTEE

E. S. MURPHY, Chairman Missoula

REVISION OF CONSTITUTION COMMITTEE

M. G. DANSKIN, Chairman ... ... Glendive

RURAL HEALTH COMMITTEE

W. E. LONG, Chairman Anaconda

R. M. STEWART Whitefish

J L. W. BREWER Missoula

M. D. WINTER .._... Miles City

J. W. CRAIG Circle

LEGISLATIVE COMMITTEE

J. M. FLINN, Chairman Helena

I W. F. CASHMORE Helena

R. W. MORRIS Helena

T. R. VYE .. Laurel

R. C. MONAHAN Butte

HOSPITAL COMMITTEE

F. F. ATTIX, Chairman Lewistown

R. L. TOWNE Kalispell

B. C. FARRAND Jordan

MEDICAL ECONOMICS COMMITTEE

J. H. GARBERSON, Chairman Miles City

J. C. SHIELDS ..... Butte

R. B. DURNIN Great Falls

I. J. BRIDENSTINE .. Missoula

PROGRAM COMMITTEE

T. F. WALKER, Chairman Great Falls

HAROLD GREGG Butte

C. H. FREDRICKSON Missoula

H. T. CARAWAY Billmgs

PUBLIC INSTRUCTION AND HEALTH COMMITTEE
PUBLIC RELATIONS COMMITTEE

J. C. SHIELDS, Chairman Butte

E. S. MURPHY Missoula

J. C. MacGREGOR Great Falls

R. D. KNAPP Wolf Point

R. L. TOWNE Kalispell

J. M. FLINN Helena

J. H. BRIDENBAUGH Billings

CANCER COMMITTEE

EUGENE HILDEBRAND, Chairman Great Falls

R. F. PETERSON Butte

C. H. FREDRICKSON Missoula

WILLIAM ROBINSON Shelby

W. F. CASHMORE Helena

E. L. HALL Great Falls

H. V. GIBSON Great Falls

HISTORY OF MEDICINE, BIOGRAPHY AND
NECROLOGY COMMITTEE

E. D. HITCHCOCK, Chairman Great Falls

J. H. IRWIN Great Falls

CHAS. S. SMITH .. Bozeman

ORTHOPEDIC COMMITTEE

J. K. COLMAN, Chairman Butte

L. W. ALLARD Billings

THOS. L. HAWKINS Helena

ARCHIE L. GLEASON Great Falls

JOHN WOLGAMOT .. Great Falls

DENTISTS, PHARMACISTS AND NURSES COMMITTEE

B. K. KILBOURNE, Chairman .. Helena

B. C. FARRAND ... Jordan

A. D. BREWER Bozeman

MATERNAL AND CHILD HEALTH COMMITTEE

F. L. McPHAIL, Chairman .. Great Falls

L. W. BREWER Missoula

P. L. ENEBOE Bozeman

D. L. GILLESPIE .. Butte

A. L. GLEASON Great Falls

E. L. HALL Great Falls

T. L. HAWKINS Helena

MAUDE GERDES Billings

B. C. FARRAND .. Jordan

C. W. PEMBERTON Butte

S. N. PRESTON .. ...... Missoula

R. C. TOWNE Kalispell

G. A. CARMICHAEL Missoula

NOMINATING COMMITTEE

J. H. IRWIN, Chairman Great Falls

A. R. FOSS Missoula

F. F. ATTIX Lewistown

NATIONAL LEGISLATION COMMITTEE

S. A. COONEY, Helena ) „ ,

A. R. FOSS, Missoula ) C°-chairmer>

MEDICAL PREPAREDNESS AND DEFENSE COMMITTEE

E. S. MURPHY, Chairman Missoula

R. D. HARPER Sidney

JOHN HAMMEREL Billings

PAUL GANS Lewistown

CONSTITUTION COMMITTEE

M. G. DANSKIN, Chairman Glendive

F. D. HURD Great Falls

R. M. MORGAN Helena

TUBERCULOSIS COMMITTEE

F. I. TERRILL, Chairman Deer Lodge

A. R. FOSS Missoula

P. L. ENEBOE ....... Bozeman

E. M. LARSON ..... Great Falls

C. W. LAWSON Havre

332

The Journal-Lancet

INTER-RELATIONS AND SCIENTIFIC PAPERS COMMITTEE

WAYNE GORDON, Chairman Billings

F. R. SCHEMM ....... Great Falls

R. F. PETERSON Butte

FRACTURE COMMITTEE

S. A. OLSON, Chairman Glendive

L. W. ALLARD Billings

E. K. GEORGE Missoula

D. S. Mackenzie, Jr. ... Havre

REHABILITATION COMMITTEE

E. M. GANS, Chairman . Harlowton

D. A. GORDON Hamilton

A. C. KNIGHT Philipsburg

ANNUAL MEETING OF THE COUNCIL OF THE
MONTANA STATE MEDICAL ASSOCIATION
July 18, 1946, 1 P.M.

The meeting of the council came to order with Dr. S. A.
Cooney presiding and Dr. R. F. Peterson acting as secretary.
Present at the meeting were Drs. C. S. Houtz, E. D. Hitch-
cock, T. R. Vye, H. W. Gregg, A. R. Foss, D. T. Berg, J. H.
Irwin, E. M. Gans, S. A. Cooney, R. F. Peterson.

Dr. J. H. Irwin made a motion that a recommendation be
given to the House of Delegates to have an executive secretary
if possible. Dr. E. M. Gans seconded the motion and it passed
unanimously.

Dr. D. T. Berg made a motion that Mr. Toomey be re-
employed as the Association’s lawyer at a salary of $500 per
year. Dr. J. H. Irwin seconded the motion and it passed
unanimously.

FINANCIAL REPORT
July 1, 1945, to June 30, 1946

June 30, 1945, Balance of cash on deposit in

Metals Bank & Trust Co., Butte, Mont. $ 5,017.95

RECEIPTS

Membership (Dues from District Societies)

Lewis & Clark County ..

..$ 140.00

Western Montana

720.00

Silver Bow County

920.00

Southeastern Montana

695.00

Yellowstone Valley

985.00

Flathead County

480.00

Fergus County

330.00

Musselshell County

.. .. 140.00

Mount Powell County

525.00

Hill County

310.00

Cascade County

972.00

Northcentral Montana

.. .. 175.00

Park-Sweetgrass

150.00

Choteau County

25.00

Madison County

100.00

Northeastern Montana

200.00

$6,867.00

Treasury Bond Coupons
Commercial Exhibits:

125.00

Sego Milk Products $

10.00

Eli Lilly & Co.

35.00

Mead Johnson & Co.

35.00

Philip Morris & Co.

50.00

E. R. Squibb & Sons
Borden’s

35.00

Nestle’s Milk Products ...

50.00

Physicians & Hospitals Supply

135.00

Ames Company, Inc.

50.00

General Electric X-ray Corp.

35.00

Lanteen Medical Laboratories

50.00

Carnation Company

50.00

Lederle Laboratories

50.00

620.00

Total Receipts

7,612.00

Total to be accounted for

$12,629.95

DISBURSEMENTS

Telephone and Telegraph Expense $ 133.04

Supplies 11.05

Printing and Stationery 288.86

Salaries 1,120.85

Journal Lancet Subscriptions 484.37

Legal (Attorney’s Retainer) 300.00

Public Health League (1945 and 1 946) 200.00

Annual Meeting 35.20

Officers’ Expense 199.60

Montana Medical History 100.00

United Public Health League __ 33.02

Dr. Cogswell’s Testimonial Dinner 176.00

Executive Committee 104.59

Program Committee 5.55

Collector of Internal Revenue ... 44.00

Montana Physicians’ Service 520.17

Miscellaneous:

Stamps 15.00

Flowers 40.30

Refund dues:

Dr. H. W. Bateman 2.00

Dr. L. T. Krogstad 25.00

Dr. R. W. Polk 25.00

Safety Deposit Box Rent 6.00

Surety Bond on Secretary 25.00

Public Health League members

at banquet 15.00

Audit books (1945) 125.00

Copies of Articles of Incorporation 10.20

Total Disbursements $4,094.80

$ 4,094.80

Balance of cash on deposit in Metals Bank &

Trust Co., Butte, Mont., June 30, 1946 .... ... 8,535.15

Total to be accounted for $12,629.95

INVESTMENT ACCOUNT
Negotiable Promissory Note:

Hospital Service Assoication of Montana, date July 24, 1941,
due on demand with interest at 6% — $1,000.00.

2/i% Treasury Bonds

Par

Accrued

of 1964-69:

Value

Interest

No. 16641 A

$1,000.00

$ 25.00

16642 B

1,000.00

25.00

16643 C

1,000.00

25.00

16644 D

1,000.00

25.00

16645 E

1,000.00

25.00

$5,000.00

Secretary-Treasurer’s Fidelity Bond:

Dr. R. F. Peterson, Butte — $10,000.00.

$125.00

R. F. Peterson, M.D., Secretary-Treasurer

Dr. J. H. Irwin made a motion that the audit of the treas-
urer be accepted. Dr. Berg seconded the motion and it passed
unanimously.

The meeting of the Council was then adjourned.

CANCER CAMPAIGN IN MONTANA

The 1946 campaign of the American Cancer
society field army in Montana was the most suc-
cessful to date with subscriptions exceeding $63,000,
or $23,000 more than the quota assigned. Mrs.
H. W. Peterson of Billings, state and regional
commander of the field army, said that 60 per
cent of the total will remain in Montana for edu-
cation and service to the cancer patient. Research
will receive 25 per cent, and the remainder will be
used for service and education on a national level.

October, 1946

333

PROCEEDINGS
of the

HOUSE OF DELEGATES
SIXTY-EIGHTH ANNUAL MEETING
of the

MONTANA STATE MEDICAL ASSOCIATION
The Civic Center, Great Falls, Montana
July 18, 19, 20

The session was called to order by the president, Dr. S. A.
Cooney. The following delegates presented credentials for the
first meeting, July 18 at 9 AM.: Cascade County — F. D.

Hurd, L. L. Maillet, R. B. Richardson, T. F. Walker, C. F.
Little; Chouteau — None; Fergus — F. F. Attix, E. M. Gans;
Flathead — T. B. Moore; Gallatin — None; Hill — Charles Houtz;
Lewis & Clark — James J. McCabe, T. L. Hawkins; Madison —
None; Mt. Powell — J. J. Malee, A. C. Knight; Musselshell —

G. A. Lewis; Northcentral — N. A. Olson; Northeastern — None;
Park-Sweetgrass — None; Silver Bow — H. W. Gregg; J. K.
Colman, Alfred Karsted; S. V. Wilking, D. L. Gillespie;
Southeastern — M. A. Shillington, M. G. Danskin, J. H. Gar-
berson; Western — J. P. Ohlmacher, C. H Fredrickson, L. W.
Brewer, A. R. Foss; Yellowstone^-H. O. Drew, D. E. Hodges,

H. E. McIntyre, John Hynes, T. R. Vye, H. T. Caraway.

Dr. H. T. Caraway made a motion and Dr. H. W. Gregg

seconded it that the minutes of the last annual meeting held
in Helena July 14, 1945, be accepted as published in the
Journal Lancet. This motion was passed unanimously. Dr.
H. T. Caraway made a motion that the minutes of the special
meeting held in Helena March 10, 1946, be accepted as sent
to each doctor. This was seconded by Dr. H. W. Gregg and
passed unanimously. Dr. H. W. Gregg made a motion that
the minutes of this last special meeting be filed but not pub-
lished. This motion was seconded by Dr. H. T. Caraway and
passed unanimously.

Dr. Cooney appointed the following to serve on the necrol-
ogy committee: Dr. F. F. Attix, chairman; Dr. M. G. Danskin,
Dr. J. J. Malee, Dr. J. J. McCabe, Dr. F. L. McPhail and
Dr. T. B. Moore. The following were appointed to serve on
the resolutions committee: Dr. T. L. Hawkins, Dr. H. W.

Gregg, and Dr. J. C. McGregor.

Secretary’s Report to the House of Delegates
The Association membership is as follows:

1946

1945

1944

1940

Total . —

404

430

444

408

Life and Honorary

Military

*39

114

107

Dues-paying

357

308

330

408

[*Revised since the meeting. 9 service men have since
been released and are practicing either in Montana (4)
or elsewhere (5) .]

You will note that the number of members of our Associa-
tion in the military services has dropped from 114 to 39. Sixty-
eight doctors have been released from the military services and
have started practice in Montana. Not all of these, however,
were members of our Association previously, but most of them
were. Therefore, approximately 39 members of Montana are
still in the services, though of course some of these will not
return to this state.

In 1944 the Montana voters defeated Initiative 48, and social-
ized medicine was defeated in the National Congress. It was
thought that the duties of the secretary’s office would diminish
in 1945 and 1946, but they have continued to increase, with
the Montana Physicians’ Service and other agencies in the state,
and with increased national pressure on socialized medicine.
Due to the increase in dues, your treasury is in the best posi-
tion it has ever been, to my knowledge. The Association can
and should now do some more definite constructive planning.

Your secretary attended the secretaries’ meeting in Chicago
on February 8 to 11, 1946, and the United Public Health
League meeting in Salt Lake City on March 16, 1946. The
report of the secretaries’ meeting was published in the Journal
of the American Medical Association and contained a large
amount of material very pertinent to medicine. The meeting
of the United Public Health League in Salt Lake City empha-
sized the excellent work that our representatives are doing in
Washington from that office. There is no question but that

this group in Washington has been the spur that started the
A.M.A. office there. It is hoped that they will work closer and
closer together. Last year the Montana State Medical Associa-
tion voted to join the group, and this year we must also vote
a means to support them financially. The other states of the
group have done all of the financing previously.

From the observation of this office for two years, the follow-
ing recommendations appear to be warranted:

1. We should have an executive secretary who would then
be able to keep the members of the Association more closely
informed of the activities in the state and also nationally, and
to keep in closer touch with the old and new agencies of the
American Medical Association and numerous national organiza-
tions, as well as other state medical societies.

2. The smaller societies of the state should consolidate with
closer, larger organizations in order to form groups that can
profitably hold regular monthly scientific sessions. One of the
qualifications for the chartering of a local society should be the
holding of regular meetings.

3. Effort should be stepped up for cooperation with the Mon-
tana Physicians’ Service and the Blue Cross.

I wish to thank the officers and members of the Association
who have been so helpful in assisting the work of the secretary.
I wish also to thank every member for being so considerate for
the things that should have been done and were not, even
though bigger changes and more activities took place in organ-
ized medicine, locally and nationally than ever before in so
short a period of time. Due to the pressure of other duties,
it will not be possible for me to continue as secretary after
this year.

R. F. Peterson, M.D., Secretary

It was moved by Dr. Walker and seconded by Dr. Malee
that the secretary’s report be accepted and made a part of
the minutes. The motion passed unanimously.

Dr. J. H. Irwin, the delegate to the A.M.A. convention in
San Francisco, made the following report:

The House of Delegates of the A.M.A. convened at 10:00
A.M. July 1st with the usual formalities; after the report of
the credentials committee showing a quorum present, the first
order of business was the selection of the recipient of the Dis-
tinguished Service Award — Dr. Anton Carlson, physiologist at
the University of Chicago was selected. Interesting addresses
were made by the speaker of the House of Delegates, R. W.
Fouts of Omaha, President of A.M.A. Roger I. Lee of Boston
and by President-elect H. H. Shoulders of Nashville, Tennes-
see. Much time and work had been spent in preparation of
these addresses and all are well worth your careful attention.
They contain much information regarding operations of the
A.M.A.; activities and suggestions for the future. These ad-
dresses will be published in early issues of the A.M.A. Journal
and should receive your careful consideration. Especially stress-
ed was the necessity for state and local societies to formulate
and put in execution plans for prepayment medical care in
order that we may successfully combat federal control. An-
other point stressed, one that has been brought to your atten-
tion before, was the fact that the best and most successful lob-
bying can be done by the individual doctor contacting the home
public and their state representatives and senators in Congress.
Also, the medical profession was urged to take a greater in-
terest in civic and state affairs, both political and social.

Dr. Wilber, ex-president of Stanford University, retiring
from chairmanship of Committees on Medical Education,
stressed the urgent necessity of state, county and individual
doctors to take more interest in mental diseases, mental hos-
pitals to the end that mental patients may receive adequate
treatment and good care in institutions, over-crowding of men-
tal hospitals with woeful under-staffing both of physicians and
nurses had led to nation-wide criticism which falls, largely, on
the shoulders of the medical profession. Interest in enactment
of laws with the object of securing ample hospital rooms, ade-
quate equipment and staffed with well trained doctors and
nurses is the responsibility of the state medical associations.
One of the most important actions taken was the establishment
of a Council on Public Relations headed by the most com-
petent man available on a full-time basis thus relieving the
editor of the Journal of much of his public relations work and
making this Council more or less a spokesman for the A.M.A.
Also cooperating with and aiding the Washington office. (The

334

The Journal-Lancet

present set-up in Washington is more of an information center
and does not undertake to do the lobbying.)

Resolutions in support of and commending Senator Taft of
Ohio for his bill on medical care were presented by the Ohio
delegation and after careful consideration by the reference com-
mittee and the discussion indicated quite general approval of
same, yet it was thought unwise to make any endorsements at
the present time as many changes, amendments, etc., would
undoubtedly be made before any action would be taken by
Congress.

The report of the Secretary of the A M. A. showed 125,471
members, the largest ever. However, of this number only 67,567
are Fellows. The distinction is that any member of a county
or state association automatically becomes a member of A.M.A.,
but application to A.M.A. for Fellowship is necessary together
with payment of $8.00 which entitles the Fellow to the Journal.
One of the reference committees recommended that state and
county societies be asked to urge all their members to apply for
Fellowship in the A.M.A.

General regret was expressed by all the delegates and by res-
olution at the retirement of Dr. Olin West as secretary and
general manager on account of ill health, to take effect April 1
of this year. Dr. George F. Lull, Major General of U S A.,
was appointed by the Board of Trustees, January 1, 1946, as
associate secretary and manager to relieve Dr. West of some
of his arduous duties and, on April 1st, as secretary and man-
ager until the meeting of the House of Delegates in July.
From all reports I hear, Dr. Lull is very ably fulfilling the
duties of said office.

Two meetings of the House of Delegates were decided upon
— one at the annual session and one early in December of each
year.

Dr. Olin West was elected president-elect and was given the
greatest ovation I have heard anyone get in the House of
Delegates.

The next meeting will be in Atlantic City.

J. H. Irwin, M.D., Montana Delegate

The second session of the House of Delegates came to order
at 2 o’clock, Thursday, July 18, with Dr. S. A. Cooney
presiding.

The first order of business at this session was a talk by Mr.
Peterson of the National Physicians Committee. He discussed
medical publicity and public relations in general. He said that
the people are interested in legislation that brings them better
medical care. He explained that the reason National Physi-
cians Committee came into being was because the government
wanted to control the medical profession through legislation.
In 1939 a bill was introduced to bring about this control but
it died in committee. He said that Washington pressure groups
are more or less frowned upon, but the voice of the physician
from home is most important. At the National Physicians
Committee meeting in St. Louis recently, the committee read
and studied all the legislation that affected medicine. This com-
mittee wanted groups from every state to go to Washington to
impress on every Senator and Congressman what medicine
thought. The groups that did go to Washington worked so
well that they changed the opinions of 18 senators and strength-
ened the opinion of many more senators. He explained that all
social legislation lately has come from one group of social plan-
ners. The Murray-Wagner-Dingell Bill died in committee, and
the Hill-Burton Bill is reported to be postponed until the pres-
ent housing shortage is met. Senator Pepper reports that much
more research must be done on his Child-Maternal Welfare
Bill. There will be a lull now in socialized medicine legislation,
but these things will crop up again when Congress reconvenes.
The effort will again be made to control the medical profession.
The government would like to control the doctors, and the
fight will be harder next time.

The following resolution was then passed by the House of
Delegates:

"Whereas, the Montana Medical Society and its individual
members recognize the effective aggressive efforts of the Na-
tional Physicians Committee to inform the public about the
benefits of the private practice system for medicine and:

"Whereas, we believe that the well-planned program of the
National Physicians Committee has been a vital part in defend-
ing of professions against legislative proposals detrimental to
the best interests and welfare of the public and the professions
and:

"Whereas, we believe that the continued expanded efforts of
the National Physicians Committee are vital to the maintenance
of medicine’s maximum opportunity to serve the American
People:

"Therefore, be it resolved: That the Montana Medical So-
ciety commend and endorse the program and activities of the
National Physicians Committee and recommends the financial
and moral support of that organization by the physicians of
the state of Montana.”

REPORTS OF STANDING COMMITTEES
History of Medicine Committee

Compiling of material to go with the first historical volume
of "Physicians of Montana up to 1900” is complete with the
exception of a small amount of material from Butte. The en-
tire material should be ready by October of this year for revis-
ing and indexing, which the American Medical Association
staff has agreed to do. The American Medical Association has
agreed to enter also into the publication of the volume but the
time of publication will depend upon material available, and
labor conditions. Pre-publication subscriptions should be taken
to help finance the output of this volume once it has been
placed in the hands of the printers. We would also recommend
that the committee gather material of the history of medicine
in Montana dating from 1900 up to the present time. No fur-
ther funds are required to complete the work aside from what
was appropriated last year.

Your committee would also recommend that a new historical
committee be appointed composed of men who can spend more
time on this work and follow up the revision and indexing and
publication of the volume.

E. D. Hitchcock, M.D., Chairman
J. H. Irwin, M.D.

Fred Attix, M.D.

Program Committee

The program for the state meeting included the following
speakers:

John A. Anderson, M.D., Professor of Pediatrics and Head
of the Department of Pediatrics, University of Utah, Salt Lake
City, Utah. Subjects: "Herpetic Infections in Infants and
Children”; "Quantitative Aspects of Fluid Therapy in Infants
and Children.” Roger O. Egeberg, M.D., Consultant for the
Ninth Service Command, Salt Lake City, Banquet Speaker.
Charles E. McLennan, M.D., Professor and Head of the De-
partment of Obstetrics and Gynecology, University of Utah
School of Medicine, Salt Lake City, Utah. Subjects: "Gyneco-
logic Bleeding,” "Pregnancy in Diabetics.” O. Theron Clagett,
M.D., M.S., F.A.C.S., Assistant Professor of Surgery, Mayo
Foundation, Graduate School, University of Minnesota. Head
of Section, Division of Surgery, Mayo Clinic, Rochester, Min-
nesota. Subjects: "Surgery of the Stomach,” "Surgery of the
Aged.” Emil Goetsch, M.D , Professor of Surgery, Long Is-
land College of Medicine, New York City. Subject: "Surgery
of the Thyroid.” Byron E. Hall, M.D., Assistant Professor of
Medicine, University of Minnesota, Department of Medicine,
Mayo Clinic, Rochester, Minnesota. Subjects: "The Effect of
Folic Acid on Macrocytic Anemias,” "Radioactive Phosphorus
Therapy.” Kenneth Swan, M.D., Professor and Head of the
Department of Ophthalmology, University of Oregon Medical
School, Portland, Oregon. Subject: "Eye Emergencies.” Wal-
ter S. Priest, M.D., Associate in Medicine, Northwestern Uni-
versity, School of Medicine, Chicago, Illinois. Subject: "Anti-
biotic Therapy of Sub-acute Bacterial Endocarditis with Autop-
sy Findings in Ten Cases.” Eugene Hildebrand, M.D., Great
Falls. Formerly: Pathologist, Passavent Memorial Hospital,

Chicago, Illinois. Subject: "Antibiotic Therapy of Sub-acute
Bacterial Endocarditis with Autopsy Findings in Ten Cases.”
M. A. Shillington, M.D., Chairman
T. F. Walker, M.D.

R. F. Peterson, M.D.

October, 1946

335

Cancer Committee

Your chairman attended the meeting of the American Cancer
Society in Chicago, November of 1945, and there obtained
many ideas and thoughts regarding effective cancer control. It
was then thought that an immediate effort would be made with
the cooperation of the Field Army to establish a program of
refresher courses for the doctors of Montana and also to sub-
mit a plan for the establishment of detection clinics in Mon-
tana.

After investigation it was found that the postgraduate facili-
ties of the adjacent medical schools are so overtaxed that it will
probably be a little time before any effective program of re-
fresher courses can be worked out and put in effect.

The question of detection clinics in a sparsely settled popu-
lation such as Montana has is a difficult one to work out and
must be handled with great care or harm will be done and
local physicians will be antagonized. It is, however, probably
possible to work out a plan which would at least mark the be-
ginning of such a program in Montana.

A word must again be said about the work of the Field
Army, who have again organized the state to a remarkable
degree.

During the recent campaign for funds, Montana with a
$40,000 goal reached over $63,000.

The American Cancer Society of Montana has many projects
which will be of great interest. A library project, a loan library,
and exhibits for fairs are among these projects. Also a series
of slides and films for use by physicians for their own instruc-
tion at society meetings will be available.

Now that the war is over and our medical profession will be
replenished and stabilized, it is our earnest recommendation
that both these matters be given earnest study and considera-
tion.

J. H. Garberson, M.D., Chairman

H. H. James, M.D.

J. H. Bridenbaugh, M.D.

J. M. Nelson, M.D.

C. F. Little, M.D.

Medical Insurance and Legal Affairs

P. E. Kane, M.D., Chairman

Medical Publications

A. R. Foss, M.D., Chairman

Medical Economics

Your Economics Committee has functioned very little dur-
ing the year. The special committee which was appointed has
carried on in the organization of the Montana Physicians’ Serv-
ice Association which was eventually adopted by your Associa-
tion and is now beginning to function essentially along the
lines recommended by this committee at the meeting one year
ago.

The matter of personal insurance both health and accident,
for the doctors of Montana has been called to the attention of
this committee. Mr. R. C. Abbott of Great Falls representing
the Loyalty Group Insurance Plan, has called upon the various
members of the committee. His plan is in effect in a great
many states among professional groups and is already operative
in Montana in the Yellowstone County Society and in the
Cascade Society. It is our understanding that it can be offered
to the members of the State Association without regard to age
or physical examination. It is the recommendation of this com-
mittee that this plan be approved by the House of Delegates
that the opportunity be submitted to the members of the state
association to join with the understanding that if 50 per cent or
more will join they can be handled as a group of the State
Medical Association.

J. H. Garberson, M.D., Chairman

A report was then given by Dr. Schultz of the Veterans
Service Bureau. Dr. Schultz pointed out that in April of this
year Washington and Oregon joined the Veterans Service
Bureau for veteran care, and this service has proved very suc-
cessful. He said that last month Idaho joined through its med-
ical association. This service can be made effective in Montana
through the Veterans Service Bureau or through the State
Association. The contract is no more than an agreement on a
fee basis. The fees are made up on the basis of a cross section

of the state. Dr. Schultz feels that the best model contract
and fee schedule is now operating in the state of Ohio. He
said that the Washington fee schedule was drawn up hurriedly
and is not sufficient to cover the needs. The Ohio plan, unlike
most other plans, covers psychoneurotic cases with fees pro-
vided accordingly. A veterans plan to be successful must be
uniform throughout. This veteran service plan may only pro-
vide for out-patient, service-connected disabilities and also serv-
ice for a veteran connected with the G. I. education bill, whether
out-patient or hospital cases. It provides for examination and
counsel. Non-service illnesses or accidents may be hospitalized
in Veterans Hospitals only if rooms are available. The first
examination and care until examination shows the injury or
illness is not service connected, can be considered as claimable
medical care. For example, organic heart disease, arthritis and
almost any general chronic illness, within one year of discharge,
is considered service connected. Doctors may treat malaria cases
at home. These service connected cases should be reported
within seven days to the Bureau. Under this plan, the doctor
would keep track of all the service given to veterans each month
and submit a bill to the Veterans Service Bureau for that
month. The Bureau would in turn send the doctor a check for
the amount. It was pointed out that dentists and pharmacists
are now negotiating to provide care for veterans on the same
type of plan. Dr. Schultz suggested that the president enter
into negotiations to enter into an agreement that would be satis-
factory to the Veterans Administration and to the Medical
Association, either in connection with Montana Physicians’
Service or the Association itself.

Dr. H. T. Caraway made a motion that the above matter
be referred to the Medical Economics Committee for considera-
tion and that they report to the House of Delegates. Dr. H.
W. Gregg seconded the motion and it passed unanimously.
After due consideration, the Medical Economics Committee
made the following report:

"Inasmuch as the Montana Medical Association has an or-
ganization already set up, namely the Montana Physicians’
Service Association, as its own organization for the purpose of
handling such matters, and since, according to the information
available to this committee, failure to belong to the said Mon-
tana Physicians’ Service will not disbar a physician from par-
ticipating in the Veterans Administration Program, it is the
recommendation of your committee that any contract with the
Veterans Administration be with the Montana Physicians’
Service Association.”

J. H. Garberson, M.D., Chairman

F, F. Attix, M.D.

H. T. Caraway, M.D.

M. A. Shillington, M.D.

It was moved by Dr. Garberson that the above recommenda-
tion be accepted. This motion was seconded by Dr. Walker,
and the recommendation was unanimously accepted.

Postgraduate Committee

F. R. Schemm, M.D., Chairman

Fractures Committee

S. L. Odgers, M.D., Chairman

Tuberculosis Committee

F. I. Terrill, M.D., Chairman

Advisory Board of Woman’s Auxiliary

The affairs of the Woman’s Auxiliary to the State Medical
Association were in good order. No meeting of the Advisory
Board was held. Individual members of the board were con-
sulted by local auxiliaries as to programs, policy, and strategy.

It is believed that two of the proper chief objectives of the
Auxiliary are: (1) to promote friendly relations among the
Auxiliary members and among the physicians themselves; (2)
to urge individual members to use their influence thoughtfully
and purposefully within the various organizations to which they
belong, to the end that the Auxiliary group on the one hand,
and lay groups on the other, may increasingly come to have a
sympathetic understanding of each other’s points of view and
problems.

J. P. Ritchey, M.D., Chairman

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Orthopedic Committee

During the fiscal year ending with the state meeting, your
Orthopedic Committee has not found it necessary to hold any
formal meetings. Dr. Colman and myself have had several
informal discussions regarding orthopedic problems, none of
which were of such a nature that they required further consid-
eration by committee members or the Medical Association.

Our relationship with the Crippled Children’s Division of
the State Board of Health has been pleasant and satisfactory,
and clinics were held biannually, at appropriate centers through-
out the state where crippled children are gathered by ortho-
pedic and public health nurses for examination. The results of
these examinations are dictated at the time of examination with
recommendations as to further treatment. Cases in need of
surgical care are investigated by the Welfare Service, and if
they are found eligible for financial assistance they are assigned
to an orthopedic surgeon for this care at state expense. If they
are not state cases they are advised as to what should be done
and are allowed to select the surgeon of their choice. Cases
eligible for state financial aid are treated according to a fixed
schedule that has previously been arranged by the Orthopedic
Committee and the Crippled Children’s Division. The fee on
the whole is satisfactory. In some instances the work required
is out of proportion to the fee paid, but we realize that the
Crippled Children’s Division must accommodate the cost of
crippled children care according to their budget.

During the past year we have had an unusually large num-
ber of infantile paralysis cases. The expense of caring for these
cases has been assumed by the National Foundation for In-
fantile Paralysis. The National Foundation, through its local
chapter, has arranged a program independent of the Crippled
Children’s Division. It seems to some of us, who are directly
connected with this work, that it might be better to combine
in some manner that is satisfactory to all concerned, the Na-
tional Organization work and the Crippled Children’s Division
program. In this way the bills would all be paid by the Crip-
pled Children's Division, who in turn would transmit these
particular bills to the National Foundation for reimbursement.
The Crippled Children’s Division is following certain definite
standards for hospital and surgical qualifications that would
automatically be made available to the National Foundation,
who are not in a position to attempt to qualify or direct cases
through certain men who are known to have the necessary
qualifications for handling these cases.

L. W. Allard, M.D., Chairman
J K. Colman, M.D.

B. K. Kilbourne, M.D.

Industrial Hygiene Committee

A. T. Haas, M.D., Chairman

Rocky Mountain Conference Committee

This committee reports that the Rocky Mountain Conference
in Las Vegas, New Mexico, has been postponed until next year.
The reason for this is that the war has so recently ended and
there are too few men back in practice. The New Mexico
group has been in contact with the committee and they have
reported that all plans for that conference have been postponed.

H. W. Gregg, M.D., Chairman

Maternal and Child Welfare Committee

Dr. F. L. McPhail suggested approval by the Montana State
Medical Association of Academy of Pediatrics survey of ma-
ternal and child health needs.

Dr. L. W. Brewer made a motion that this body favor pro-
mulgation of a law modeled after adjacent states requiring pre-
marital Wassermann and examination. Dr. B. K. Kilbourne ex-
plained that the model law does not prohibit a 4 plus Wasser-
mann case from marrying but only informs prospective marrying
couples of the fact and how it will affect their future. Dr. D.
T. Berg suggested that the law be read and interpreted by Mr.
Toomey, the attorney. Mr. Toomey explained that the model
only informs both contracting parties and they may get mar-
ried anyhow. In this model law, no responsibility is placed
upon the doctor as in previous laws.

The motion as made by Dr. Brewer was seconded by Dr.
Gregg and it passed unanimously.

F. L. McPhail, M.D., Chairman

Necrology Committee

During the past year the deaths of the following named
physicians and surgeons in Montana are reported:

Dr. P. L. Greene, Livingston, (January 5, 1946) .

Dr. J. H. Hunt, Glendive, (March 22, 1946).

Dr. G. J. McHeffey, Butte and Billings, (March, 1946).

Dr. S. E. Schwartz, Butte, (March, 1946) .

Dr. C. E. Blankenhorn, Great Falls, (March 6, 1946).

Dr. J. W. Fennell, Missoula, (February 23, 1946) .

Dr. H. L. Koehler, Missoula, (June 8, 1946) .

Dr. W. W. Johnson, Savage, (November 15, 1945).

Dr. Jacob Thorkelson, Butte, (November 20, 1945).

Dr. L. W. Smith, Butte and Poison, (November 18, 1945).

Dr. C. F. Jump, Helena, (October 22, 1945) .

Dr. B. V. McCabe, Helena, (August 24, 1945).

Dr. W. N. King, Missoula, (July 16, 1946) .

Whereas, Divine Providence has removed by death from our
midst these respected and honored members of the medical pro-
fession of Montana and called them to their eternal rest from
the arduous duties well performed in the service of their pa-
tients. Therefore, we recommend that this report be spread on
the minutes of the Medical Association of Montana in respect
to the memory of our departed colleagues, who have served so
faithfully in upholding the high ideals of the medical pro-
fession.

F. F. Attix, M.D., Chairman

M. G. Danskin, M.D.

J. J. Malee, M.D.

J. J. McCabe, M.D.

F. L. McPhail, M.D.

T. B. Moore, M.D.

Dentists’ Pharmacists’ and Nurses’ Committee

NURSES

During the past year, the Montana State Nurses Association
has established a new full-time position whose office is with the
secretary of the State Nurses Association. This position is a
professional counseling and placement service. The State Asso-
ciation, at the present time, shows a membership of 760. There
are registered with the placement service 50 vacant positions.
Eight nurses have listed credentials and are looking for posi-
tions other than the ones in which they are working at present.
The State Board of Nurse Examiners shows that there are 3200
nurses currently registered in the State of Montana but those
giving Montana addresses at the present time are 1900. There
are 950 students in training in the nursing schools in Montana
at the present time and an approximate additional enrollment
of 200 before the end of 1946.

DENTISTS

The Secretary of the State Board of Dental Examiners re-
ports that two of Montana’s dentists lost their lives while serv-
ing in the Armed Forces during the war. Approximately 70
per cent of those who were in the service have returned to
practice within the state. The State Board of Dental Exam-
iners has issued twenty new licenses for the practice of den-
tistry in Montana during the present year. There is still a
great need for additional dentists within the state.

PHARMACISTS

The State Board of Pharmacy has nothing to report.

B. K. Kilbourne, M.D., Chairman
B. R. Tarbox, M.D.

W. H. Stephan, M.D.

Nominating Committee

The Nominating Committee met and have the following
nominations to make:

For President-Elect: Dr. L. W. Allard, Billings; Dr. F. E.
Keenan, Great Falls.

For Vice President: Dr. D. T. Berg, Helena; Dr. C. H.
Fredrickson, Missoula.

For Secretary: Dr. H. T. Caraway, Billings; Dr. Alfred

Karsted, Butte.

For Delegate to AM. A.: Dr. R. F. Peterson, Butte; Dr.

J. J. Malee, Anaconda.

For Alternate Delegate to A M. A.: Dr. T. L. Hawkins,

Helena; Dr. T. R. Vye, Laurel.

For Councilors: District No. 1: Dr. G. W. Setzer, Malta;
Dr. R. E. Ryde, Glasgow. District No. 2: Dr. C. W. Law-

October, 1946

33 7

son, Havre; Dr. D. S. McKenzie, Havre. District No. 7: Dr.
T. B. Moore, Kalispell; Dr. H. D. Huggins, Kalispell. Dis-
trict No. 10: Dr. A. C. Knight, Philipsburg; Dr. L. G.
Dunlap, Anaconda.

For five names recommended to the governor of Montana
for Board of Health appointment: Dr. L. W. Brewer, Mis-

soula; Dr. C. S. Houtz, Havre; Dr. J. C. Shields, Butte; Dr.
W. H. Stephan, Dillon; Dr. M. D. Winter, Miles City.

For Executive Committee: Dr. J. C. MacGregor, Great
Falls; Dr. F. F. Attix, Lewistown.

Dr. Malee requested that his name be withdrawn from the
ballot.

Dr. Karsted requested that his name be withdrawn as a can-
didate for secretary.

Dr. Wilking was nominated from the floor for secretary, but
he requested that his name be withdrawn and that a unani-
mous vote be given Dr. Caraway.

Dr. Shillington moved that Dr. Cooney’s name be put on
the ballot for the Executive Committee. Dr. Attix seconded
the nomination and it passed unanimously.

Dr. Colman moved that the Board of Health nominations
be accepted. Dr. Gregg seconded the motion and it passed
unanimously.

Dr. Malee made a motion that the delegates vote on one
ballot. Dr. Gregg seconded the motion and it passed unani-
mously.

Dr. Shillington made a motion that the nominations be
closed. Dr. Brewer seconded the motion and it passed unani-
mously.

A. R. Foss, M.D., Chairman
E. M. Gans, M.D.

L. G. Dunlap, M.D.

Report on National Conference on Rural Health

Dr. E. M. Gans, who attended the first annual meeting,
National Conference on Rural Health, March 30, 1946, in
Chicago, Illinois, made the following report:

The meeting was called to order by F. S. Crockett, M.D.,
chairman, Committee on Rural Medical Service,. American Med-
ical Association, who outlined the purpose of the meeting.

1st: To ascertain where medical service is needed, and sug-
gested this to be ascertained by the local medical societies and
they to take steps to plan to take care of their own communities.

2nd: The people in the rural community to pay what they
can and the balance to be supplemented by local taxation.

3rd: To have a committee of the physicians and a committee
of the F.S.A. meet and work out a satisfactory solution of the
Rural Health problems, but not to be done by federal aid.

Dr. West, secretary, American Medical Association, gave a
short talk along the same lines as Dr. Crockett, and concurred
in Dr. Crockett’s statements.

Ransom E. Aldrich, Mississippi, chairman, Medical Care
Committee, American Farm Bureau Federation, then spoke of
the need of medical care in rural areas. He stated, "We have
not adequate medical care for rural communities.’’ He elab-
orated at some length on the lack of medical care in rural
areas. However, he also stated that medical care of rural com-
munities should be controlled by the community, and if this is
not done, it will be done for them and the local community
will lose control. That that chief problem in rural communities
is cost, and suggested that some prepayment plan for hospital,
ambulance and medical care should be worked out.

Leonard W. Larson, M.D., North Dakota, member, Com-
mittee Rural Medical Service, American Medical Association.
His talk was on the subject of making living conditions in
rural areas and the medical practice more attractive, so that
physicians would locate in these areas and be assured of good
living conditions, schools and hospitals. But he stated that no
hospital was good unless adequately equipped and staffed.
Good roads would bring the patients to the doctor and so
would lower the cost. Good prepaid medical service is the solu-
tion, if the farmer will and can pay for it. He also stated that
community health centers is one solution and thinks it would
encourage young physicians to locate in rural areas. Close
cooperation between farmers and physicians would provide ade-
quate medical service with reasonable cost.

Fred R. Mott, M.D., U. S. Public Health Service, Chief
Medical Officer, Farm Security Administration. He stressed the
need of preventative medicine in rural areas, by having more

nurses and health officers. He claims an outlay of one dollar
per person by local community to be matched by an equal
amount by the Public Health Service would solve this prob-
lem. Because of the low income of the American farmer, the
farmer could not afford to pay the fee of a dollar a mile, and
thought that maybe the physician could not do it any cheaper.
That the average income of the farmer was $760.00 a year,
and even lower than that in Nebraska and some other states.
He also favored the Truman Health Bill.

Victor Johnson, M.D., secretary, Council on Medical Edu-
cation and Hospitals, American Medical Association, stated
that scholarships might be provided for young men from rural
areas, if possible, entering the medical profession, provided
they agreed to practice in rural areas for a period of years, but
this proved to be a failure. He also stated that medical care in
the rural areas must be of high quality by physicians and hos-
pitals. That some plan must be found for the care of rural
areas, but that so far no feasible plan was offered by him.

Howard Strong, Secretary, Health Advisory Council, Cham-
ber of Commerce of the United States, Washington, D. C.
He stated that there were three plans available: (1) Service by
private physicians, (2) Service through hospitals, (3) Service
through Public Health. That cities have larger number of
physicians than country areas. That 60 per cent of the counties
have full time health officers, so that the nation is becoming
health conscious, and that a study was being made of hospital
needs. One suggestion was to have a base hospital, centrally
located, with teaching and laboratory facilities. Then to have
district emergency hospitals, without teaching or laboratory,
where emergency care can be given, and then transport the
patient to the base hospital. The rural medical care should be
a local problem and handled by the local community. He also
advocated a nation-wide plan for better health.

Leland B. Tate, Ph.D., Rural Health Service, The Farm
Foundation. He stressed research for health education in rural
areas and improving rural living conditions, and the need to
know the characteristics of farm people; settle the conditions
and difficulties arising in farm communities; find out how the
farmer thinks and reasons. Try to make subject matter clear to
farm people by understanding their educational status and
learn how to approach them and get their economic reactions.
That health education may find the answer to medical service
for farm communities.

Mrs. Charles W. Sewell, administrative director of American
Women of American Farm Bureau Federation. Mrs. Sewell
was not in favor of federal aid, nor the Murray-Dingell bill.
She did favor the Hill-Burton bill. She also stressed educating
farmers in health problems and advised working out a suitable
program to equalize medical cost to farm income. She advised
meetings of farm groups and physicians in the local communi-
ties.

The following is the program for action of state rural health
committees:

What should the state committee on rural medical service
undertake? Meet with interested farm groups — Farm Bureau,
Grange, Farmers Union, and agree on objective for common
effort. Three general types of activity may be considered:

1. Hill-Burton bill. See that sound judgment is exercised in
placing of facilities and other details applying to rural areas,
(a) Insistence on and devising methods for maintenance of
high professional standards in all facilities constructed so that
more service will not mean service of lower quality, (b) De-
ciding what constitutes the unit to be served by various types of
facilities, number of people, distance the sick can be transport-
ed, desirability of a public ambulance service. The present
available professional personnel and possibility of attracting
more, (c) Deciding what is meant by diagnostic center and
health center and their relation to the hospital as they should
apply in each state, (d) Close affiliation with agencies of state
government created to administer the Hill-Burton bill or like
legislation.

2. Extending to country people the benefit of prepayment
plans for catastrophic illness and hospitalization. Special plans
for marginal farmers who may be in part medically indigent,
but should be encouraged to pull their pound.

3. Promotion of health education among farm people. Initia-
tive here must reside in organized farm groups: Parent-Teacher,
4H Clubs, Home Economics Clubs, Boys’ Camps, extension

338

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departments of state agricultural schools, accident prevention
and first aid, sponsoring proper kind of publicity in farm
press, local papers and local radio.

4. Conference of rural and health leaders, sponsored by
state colleges of agriculture. Ohio University is a good example.

E. M. Gans, M.D., Chairman

Dr. Danskin made a motion and Dr. Gregg seconded it
that tentative drafts of the revised constitution shall be sent to
each member for consideration within 90 days. Then a printed
copy shall be sent to each member earlier than two months
before the next annual meeting for consideration and adoption.
This motion was unanimously passed.

Dr. Victor H. Vogel, chief medical officer of the office of
Vocational Rehabilitation of the U.S.C.H.S., gave a history of
the Vocational Rehabilitation program and stated that their
program is to purchase medical advice and care from practi-
tioners of Montana for cases having the following qualifica-
tions: (1) The patient must have reasonable chances of em-
ployability. (2) The condition must be either static or slowly
progressive. (3) Care cannot be given for purely humanitarian
reasons only. (4) Care cannot be given for acute illnesses. He
outlined the state program, and further details should be ob-
tained from the office in Helena, Montana.

Dr. Garberson made a motion that the House of Delegates
consider the matter of health and accident insurance for the
doctors. Dr. Gregg seconded the motion and it passed unani-
mously.

Dr. R. F. Peterson recommended to the House of Delegates
that an executive secretary be employed by the Montana State
Medical Association. In the following discussion, Dr. McCabe
was opposed to electing an executive secretary and suggested
that the regular secretary be reimbursed. Dr. Shillington point-
ed out that it was difficult for a full-time doctor to take care
of the job properly. After a lengthy discussion it was felt that
a doctor is more qualified to take care of the job than a lay-
man. Dr. Shillington made a motion which was seconded by
Dr. J. T. McGregor that the society approve up to $250 per
month for the secretary’s help if necessary for next year. This
was passed unanimously.

Maternal and Child Health Committee

On July 16, 1946, Dr. Edythe Hershey left Montana to
take up her new duties as a Regional Consultant for the Chil-
dren’s Bureau in five southern states. In recent years there has

been considerably more interest on the part of the doctors in
maternal and child health problems. Hand in hand with this
interest has come a marked reduction in the maternal and in-
fant mortality rates in this state.

The progress since the establishment of the Division in 1917
is noteworthy. The maternal mortality rate has decreased from
118 per 10,000 live births in 1917, to 14 in 1945; and the

infant mortality rate has decreased from 79 per 1,000 live

births in 1917, to 34 in 1945. Many factors are responsible for
this remarkable improvement. These reductions in mortality
rates could not have been accomplished without the very fine
cooperation of the medical profession. It is believed, however,
that the educational program carried to the people of the state
has played a very important part in the saving of mothers and
babies.

It is important to recognize that the Montana Medical Asso-
ciation, through its Maternal and Child Health Committee,
has served as liaison with the medical profession and has made
possible the accomplishment of much that would have been
impossible without this participation.

It is only through understanding, support and participation
of the medical profession with public health authorities in the
development of an educational program through lay groups
such as the Montana Tuberculosis Association, the Montana
Federation of Women’s Clubs, and Parent-Teacher’s Associa-
tions, as well as the Department of Public Instruction which
has worked closely in integrating the school health program,
that a competent health education program can be carried out
consistently and whole-heartedly. Your Maternal and Child
Health Committee desires to express its appreciation for the
work accomplished by Dr. Hershey during her eight years in
Montana as Director of the Division of Maternal and Child
Health.

During the war years, over 6,000 mothers and babies have
been authorized for care under E.M.I.C., with obligations for

payment of over a half million dollars since May, 1943. The
Director of the Division for Maternal and Child Health has
been responsible for all authorizations and approval of medical
and hospital claims. Administrative costs have been kept at a
minimum. At the present time a study of the E.M.I.C. case
records is being made. This study will include not only quality
of care, but will give some indication of morbidity, as well as
full mortality for the cases under the program. The cost of
administration, and the case costs will be revealed. There is
a rather complete data of hospital costs for all of the larger
hospitals in Montana, showing cost statements for three con-
secutive years. Material from these statements should be help-
ful for those with allied interests, such as The Blue Cross, and
our hospital administrators, and should prove helpful in study-
ing hospital costs in this state.

Post-Graduate Courses. The sub-committee composed of Dr.
Gillespie, Dr. Brewer, and Dr. Eneboe, is working on a post-
graduate program for next fall. These courses will follow,
according to the present plan, the system followed prior to
the war.

A sub committee composed of Dr. Gerdes, Dr. Farrand, and
Dr. Preston is reviewing all literature relating to Maternal and
Child Health, sent out by this Division of the State Board of
Health.

Premature Program. A sufficient number of Gordon-Arm-
strong incubators may be purchased to be utilized in hospitals
which agree to participate in the premature program and accept
consultation and advisory services. If we are to reduce our
infant mortality rate still further, a program of improved care
for the premature babies must be carried out. Plans are being
studied for facilities which will make it possible for a pre-
mature infant to receive adequate premature care in any part
of the state.

Pre-marital Legislation. This legislation was previously pro-
posed by the state medical association on the recommendation
of this committee, but the executive committee of the state med-
ical society did not take any active part in promoting this
legislation. It is our belief that this bill should be introduced
at the coming legislature and that it should be supported by
the medical profession. This decision is in line with the activity
of 33 states in insisting upon pre marital examination and
Wassermann tests. Each neighboring state has passed similar
legislation.

Maternal Mortality Studies. Dr. Mattison, director of the
Maternal and Child Health division of the State Board of
Health, succeeding Dr. Hershey, is making a study of material
collected over the last five-year period. As this data is reviewed
and completed, the results will be written for a published report
for the medical profession.

Infant Mortality Studies. The records and questionnaires as
filled out by the attending physicians are available for tabula-
tion for the five-year period. These will be tabulated and
studied when more help is available for this study.

Montana is cooperating with a nation-wide child health study
which has been initiated by the American Academy of Pediat-
rics with Dr. Gleason as state chairman. This study has been
supported by this committee and Dr. Mattison has been ap-
pointed to serve as executive secretary. It is hoped that the
house of delegates will approve this study and enlist the interest
of all physicians.

Once again an effort is being made to organize those inter-
ested in obstetrics and gynecology into a small society for the
advancement of obstetrics and gynecology in this state.

Legislation was passed in 1945 which was to provide for a
hygienic laboratory to operate a blood plasma bank and prepare
plasma. It has been impossible to obtain a building to carry
out this program, although the equipment has been purchased.
In the meantime plasma was made available by the American
Red Cross through the State Board of Health, and is adequate
to meet the needs for this next year. In the meantime, this
gives an opportunity for reconsideration of the services that
should be rendered through the hygienic laboratory in accord-
ance with the law, and probably some changes might be made
in the near future in regard to this plan. The question has
been raised as to services which might be offered for Rh typing
facilities in the small hospitals and outlying areas.

Licensing of maternity homes and hospitals, according to law,
has been delayed due to lack of personnel during the war.

October, 1946

339

Reinspection of the hospitals and maternity homes has already
begun. Licensing will be completed when this information is
available.

It is recommended that each hospital staff appoint an ob-
stetric committee to assure conformity with the provisions of
this law and to set up obstetric regulations and procedures.

F. L. McPhail, M.D., Chairman

Election

The following were elected to serve as the officers for the
coming year:

Dr. L. W. Allard, Billings, President-Elect.

Dr. C. H. Fredrickson, Missoula, Vice President.

Dr. H. T. Caraway, Billings, Secretary-Treasurer.

Dr. R. F. Peterson, Butte, Delegate to A.M.A.

Dr. T. L. Hawkins, Helena, Alternate Delegate to A.M.A.

Dr. G. W. Setzer, Malta, Councilor from District No. 1.

Dr. C. W. Lawson, Havre, Councilor from District No. 2.

Dr. T. B. Moore, Kalispell, Councilor from District No. 7.

Dr. A. C. Knight, Philipsburg, Councilor from District
No. 10.

Dr. M. A. Shillington will serve as President for the com-
ing year.

Dr. S. A. Cooney was elected unanimously to service on the
Executive Committee for a two-year period.

Dr. Hurd made a motion that a vote of thanks be given
Dr. J. H. Irwin for his long and faithful service as a delegate
to the A.M.A. from the Montana State Medical Association.
A rising vote of thanks was accorded Dr. Irwin.

Dr. C. H. Fredrickson invited the 1947 session to Missoula,
Montana. Dr. Walker made a motion that the delegates accept.
This was seconded by Dr. Hurd and carried unanimously.

Dr. Hurd made a motion that $1 per paid-up member be
paid to the United Public Health League for this year’s sup-
port of their program and that the check be accompanied by
a letter suggesting an arrangement be made with the Execu-
tive Committee of this association for the matter of solicita-
tion and support for the next year, and also that a process of
unification of the various Washington offices be undertaken.
This was seconded by Dr. Shillington and passed unanimously.

A long discussion was held regarding the advisability of the
State Association supporting financially speakers for the vari-
ous more specialized groups of the Association. No final action
was taken after a number of motions that had been made were
withdrawn.

Dr. Shillington moved that the House of Delegates recess
until 8 A.M. the next day and this was seconded by Dr.
Gregg and passed unanimously.

Dr. Attix suggested that the N.P.C. be contacted to have
information available for use by the Montana Public Health
League for public use.

Dr. Shields made a motion that the Committee on Public
Relations act as advisory committee to the medical advisor to
the Montana Public Health League. This was seconded by Dr.
Richardson and passed unanimously.

Dr. Hawkins made a motion that Dr. McPhail of Great
Falls edit his report for publication in the Montana Health
and the public press. This was seconded by Dr. Malee and
passed unanimously.

Dr. Caraway made a motion that the House of Delegates
extend a vote of confidence to the State Board of Health. This
was seconded by Dr. Gregg and passed on voice vote.

Dr. Shields made a motion that the House of Delegates
adjourn and immediately reconvene as the administrative body
of the Montana Physicians’ Service. Dr. Hurd seconded the
motion and it was passed unanimously.

. (All committee reports were duly accepted. Some committees
had no reports and are therefore not listed.)

Medical Service and Public Relations Committee

In the past year a number of medical issues have clarified
themselves. It is appropriate to consider these under two
headings.

The first concerns the legal status of medical practice. It
derives from the continuing legislative attempts now in progress.
These, with the aid of increasing pressure from propaganda
groups, aim at a revolution in control of the theory and prac-
tice of medicine.

This move is important not only because of its direct attack
on medical practice, but because it also aims to split away from

their position as partners of the physician the ancillary groups,
such as the hospital and nursing professions. Let no one as-
sume that once universal compulsory health insurance becomes
a fact, we shall not find our guidance and counsel of these pro-
fessions displaced downward in the scale by their need to cul-
tivate political favor.

This legislative problem, by its momentum, has developed
into our number one headache. In the long run, it cannot be
divorced from the wider issues of public relations which consti-
tute the second topic of our report. However, its urgency re-
quires us to consider it separately and primarily and in terms
of action.

It must be apparent from the testimony currently being
quoted in the Journal of the A.M.A. from the hearings of the
Senate committee on education and labor, that the essence of
our immediate defense is now clear. It consists in the promo-
tion, operation, and perfection of voluntary plans for prepay-
ment of medical expense, and extension of membership in these
plans to the low-income portion of the population. Arguments
of theory and references to the record of the profession in im-
proving the health of our nation, fall on ears which, if not
deaf, are at least attuned to only the language of the vote.
Gone with monarchies, Van Dyke beards, and laudable pus,
are the days when the deepest convictions of professional men
might be expected to weigh favorably in the scale against en-
thusiasms of "social scientists” or the political aspirations of
labor bosses.

Therefore our defense has come to consist of substituting
voluntary plans on as wide a base as may be necessary to sat-
isfy those who may otherwise be attracted to the bait so per-
suasively displayed by pressure groups. The A.M.A. council
on Medical Service and Public Relations estimated a few weeks
ago that by the end of 1946, there will be in operation volun-
tary plans in 42 states.

Our constructive program in defense may be surveyed in
future years and thought to have been proper and good, or
it may be assayed and condemned. But no thoughtful person,
reading the current testimony, can doubt that the fate of "com-
pulsory health insurance” legislation, and at the same time, the
immediate future of the practice of medicine, depends in large
measure on the success of voluntary plans. Therefore, your
committee recommends that each member of the state associa-
tion make it his business to support the Montana Physicians
Service in principle and practice to the utmost of his fairness
and ability. By insuring the successful operation of our own
plan, we can establish a favorable reaction towards the profes-
sion in the economic zone of public relations, where it will be
particularly helpful.

The second portion of this report proposes a course of action
for the profession, through the A.M.A. and its Council on
Medical Service and Public Relations. No claim is made for
originality in any of the suggestions which follow, and in fact,
acknowledgment is made directly to Dr. Bradford Murphey of
Colorado and Dr. Alfred Adson of Minnesota, whose com-
ments along these lines recently attracted the attention of your
committee.

Four correlated programs are hereby recommended. These
can be effective only through positive action by the A.M.A.
If this report is adopted, it is expressly directed that the Mon-
tana delegate to the A.M.A. meeting submit a resolution call-
ing for the establishment of these four national programs
It is further expressly directed that this resolution be submit-
ted immediately, in writing, to the A.M.A., and again submit-
ted from the floor at the next meeting of the house of dele-
gates of the A.M.A.

The first program is the establishment of a statistical re-
search into the complete preventive and theraoeutic services
offered and used bv states and areas. This should be of thor-
oughness and detail at least equal to that now displayed by the
A.M.A. in evaluating medical education and hospital service.
The results of this study should be published both in con-
densed versions to readers of the Journal of the A.M.A., and
elsewhere in complete detail, to be available to agencies and
persons interested.

The results of such a truly comprehensive study should do
one of two things, or both, in part. First: go far to dispel the
flood of biased statistics being loosed at the congressional hear-
ings and elsewhere by governmental and private agencies, con-

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cerning the state of health of this nation. Or, second: confirm
real gaps in the supply and use of medical service. In the latter
case, the remedies will become apparent, and we will be able
to police our own territory.

The second program will eventually be the direct corollary
and outgrowth of the first, — but in some respects must pre-
cede it, and consists in the establishment of a national program
of health education. Abandoning the defensive and passive
attitude which has characterized the profession traditionally, we
propose that the A M. A. take an aggressive position in health
education. Through available means of public instruction such
as school texts and films, periodicals, radio and press, the pro-
fession should freely and authoritatively reiterate the gospel of
preventive medicine in its widest sense (including personal hy-
giene, both mental and physical) .

The aspect of prevention should be the main theme of health
education, with the curative phases handled in such general
terms as will help build patient cooperation for the practitioner.
Too long the chief written interpretation of modern medicine
to the layman has been the syndicated medical column, which
usually makes the patient critical of anything except the latest
medical fad. And too long the most vivid national presenta-
tion of medical progress by radio has been a "plug” for one
or another brand of cigarettes.

No one assumes that such a program of health education
will be easy to formulate, or that mistakes will not be made.
But the excellent beginnings made by the A.M.A., and by
certain state societies such as that of New York, have shown
how it may be approached successfully.

Besides the scientific presentations suggested above, there is
another large field to be covered by this program. That lies in
presenting the public authoritatively with the facts of political
medicine abroad as compared with medicine in the U.S.A.
This can establish in the consciousness of both our political
friends and foes, the background of our stand against political
medicine. For instance, in the high schools throughout the
land this year, one of the chief topics which will be debated
is compulsory health insurance. We may be confident that
there will be a wealth of material supplied through the schools
by our opposition. In like manner we need to supply facts to
those who will try to carry our side of the argument. Even
now the parent A M. A. council is developing such a brochure
for school distribution. The same facts need wider circulation,
and the two programs just proposed, namely statistical research
and health education, should act for us. This is an important
job.

The third proposal we make, is that the Washington, D. C.,
office of the A M. A be considerably expanded. This office was
not even established by the A.M.A. until at least two other
medical organizations had seen the need and begun to meet it.
A month ago the A.M.A. was still served in Washington by
only one man who was doing his best to cover congressional
hearings, maintain contact with the important committees, fol-
low the progress of proposed medical legislation, and serve as
A.M.A. information bureau, all from a one-room office, with
one stenographer. When we are talking about the importance
of consolidating health agencies of the federal government in
one department with a chief who is of cabinet rank, it is
obvious that we must have the profession itself represented
adequately to the legislative branch.

This office should provide a service to the inquiring legis-

lator by letting him know where the profession stands in health
matters. It should also provide a service to the profession by
letting us know the same about our individual legislators.

This sort of activity may change the tax status of the A.M.A.
If so, let us increase our dues (by whatever amount is needed)
and do the job. It has been argued that the A.M.A. should
retain its tax exempt status by avoiding any semblance of lobby-
ing. Your committee feels that no other organization can do
these jobs so well as the A.M.A., if we wish them done. We
also feel that such organizations as the N.P.C., which has done
much good work, should be free to continue, and should be
supported individually, but this N.P.C. draws part of its con-
tributions from drug and manufacturing houses, and we be-
lieve the actual legislative and educational programs of the pro-
fession should be kept clear of any entangling alliances.

The fourth program we propose is that there be an A.M.A.
training program for state officers and committeemen. Your
officers could serve your interests much better in these times
of stress if they had the benefit of conference with their fellows
in adjacent states and with the personnel of the A.M.A. This
program might best be carried out by national assemblies of
state presidents, vice presidents and secretaries as an extension
of the customary annual conference of state secretaries. In
the case of committeemen, regional meetings of the various
councils would probably be more practical. We believe that
such a system of training and mutual consultation would lend
continuity to the administration of our society, perspective and
conviction to our officers, strength to our actions, and unity and
prestige to our profession. I move adoption of this portion of
the report.

One further immediate problem requires discussion. The
shortage of nurses exists nationally. Two facts are apparent as
primary causes. The first is the diversion from actual practice
of registered nurses who are either tired out by the pressure
of duty in civilian life, or fascinated by their experiences with
executive types of practice in public health or other specialized
work. That is bad enough.

But the second fact is that nursing as a career is appealing
to fewer girls, and our training schools are not being filled.
And that is worse.

It is time to wonder if the nurses aide type of service being
used by hospitals quite generally now is really operating to
keep many of the desirable candidates unavailable for regular
nurses training. This perhaps we cannot answer easily; but
one thing we can do — each can make a personal effort to in-
terest the families of his acquaintance who have girls finishing
high school to send them into training. Our influence can
help in the right direction and is sorely needed.

Your committee wishes to call for discussion on the matter
of the future policy and relationship of the state society to
two organizations, the Public Health League of Montana, and
the United Public Health League, representing most of the
western states. We have no recommendations to make in these
matters, but believe they are of fundamental importance and
that they should be discussed thoroughly and a positive action
taken with respect to each.

Respectfully submitted,

Leonard W. Brewer, M.D., Chairman
M. A. Shillington

NORTHWEST HOSPITAL ALLOTMENTS

Allotment figures to the states for the five year hos-
pital construction program authorized in the Hospital
Survey and Construction Act have been released by
Surgeon General Thomas Parran of the United States
Public Health Service. The Act authorizes the appro-
priation of $3,000,000 for statewide hospital surveys and
for planning of construction programs, and $75,000,000
annually for the actual construction of hospitals and
related facilities.

The share to which each state is entitled from the

$3,000,000 authorization for survey and planning ex-
penses is based solely on state population. For determi-
nation of the distribution of the $75,000,000 authorized
for construction, a formula is used which takes into con-
sideration both the population and the per capita income.

Preliminary estimates for survey and planning for the
following Northwest states are: Minnesota, $56,876,

Montana, $10,355, North Dakota, $11,889, South Da-
kota, $12,066; for construction: Minnesota, $1,655,700,
Montana, $231,825, North Dakota, $308,475, South
Dakota, $359,625. — Federal Security Agency Release.

October, 1946

ADDRESS OF THE PRESIDENT

S. A. Cooney, M.D.

Helena, Montana

341

It is with real appreciation of the confidence reposed in me
as your president, that I make the president’s report of my
discharge of that stewardship during the year 1945-1946 of
the Montana State Medical association.

The association year which has just closed, has witnessed
events of the first magnitude in human affairs, the cessation of
hostilities on the battle fronts of the world, the return of mil-
lions of fighting men and their supporting services to civilian
life, and the myriad of problems consequent upon the tremen-
dous dislocations and confusions caused by a war which en-
gulfed all of humanity, a war which bears the ominous title
World War II, as if others were to follow in numerical pro-
gression. The state of Montana may well be proud of its war
efforts. I am informed by state headquarters of the selective
service, that Montana furnished, in round figures, not less
than 68,000 men and women to the armed services, divided,
approximately, into 65,000 men and 3,000 women. This figure
is inclusive of all under-aged males who served in special train-
ing programs. Show me any other state with such a record.
Of the men and women who went to the Army from the
Treasure State, 1552 were never to return. In World War I,
Montana’s war deaths were, in proportion to population, 2%
greater than those of any other state, regardless of population,
considering the number of troops engaged. In World War II,
Montana’s army death rate was exceeded only by that of one
state, New Mexico. With .42% of the nation’s population in
1940, Montana contributed .48% of the army. More than one
in twenty-five will not return. They represent .59% of the
army’s total dead and missing, compared with .42% for the
entire United States population, and .48% of army strength.
Every county in Montana suffered. Silver Bow’s 120 was the
heaviest toll, with Cascade’s 119 second. Liberty and Petroleum
each gave three lives. I regret that figures for the navy have
not been finally checked and released, but that service must
comb every sea before it can finally report respecting our boys
who "went down from the mountains to the sea.”

Our profession was strongly represented in the armed forces
of the nation. Of the doctors of medicine who were practicing
in Montana under licenses issued by the state board of medical
examiners of Montana, 114 went forward into the armed
services. In every theatre of war and on the seven seas they
contributed the best they had for the protection of the Ameri-
can man-at-arms stricken in battle, laid low by disease, or over-
come by fatigue or the nerve shattering experiences of war.
In honor of all of whom I have spoken, including our own
brothers of the profession, 1 ask you now to stand, with bared
heads, for a moment of silence.

I believe it can be truthfully said that we of the profession
who remained at home, were fully mindful of the sacrifices
made by those who went into the armed services, and that we
have done within our state everything that could be done to
provide equality of opportunity upon their return to their pri-
vate practices in their former locations, or their re-establish-
ment of private practices in new locations in our state.

Notwithstanding the multiplied burdens on members of the
profession growing from war and its aftermath — burdens that
would make any year full to overflowing, the profession in
Montana has been faced with consideration of problems of the
first magnitude, and it has resolutely grappled with them. The
more important of these problems remain for our earnest atten-
tion and consideration:

(1) Socialized medicine. The proponents of socialized medi-
cine seized every opportunity during the war to advance their
cause, notwithstanding the engagements of members of our
profession overseas and in their arguments they pointed to war
conditions as justifying their efforts, regardless of the fact that
fair-minded men recognize that no sane legislation could be
based on such transient conditions. Agreeable to the directions
of your association, your president, accompanied by Dr. A. H.
Foss of Missoula, appeared before the Senate committee on
education and Labor, in the Senate of the United States, in
the week of May 28, 1946, in opposition to the Murray-
Wagner-Dingell bill, sometimes referred to as the National

Health Insurance plan. At the conclusion of our testimony
and representations on behalf of the Montana State Medical
association, Senator James E. Murray delivered to me the
original transcript covering our appearance, and I have brought
that to the convention where it is open to inspection by any
of you * I hope that most of you will take the opportunity,
either now or later, to examine this transcript, for I believe
that you will find therein irrefutable evidence that, notwith-
standing Senator Murray’s being one of the authors of the
bill, he accorded the Montana State Medical association,
through its representatives, every possible courtesy in connec-
tion with the presentation of Montana’s case. And I think
you will agree with the conclusion that, in your behalf, we
made a case for the preservation of the personal relation of
physician and client against government-ordered and govern-
ment-administered medicine. At least the testimony wi 11 indi-
cate the ready agreement with our views, of those who were
against the bill, and, as regards those who were for the bill,
agreement in principle that this personal relation must be main-
tained at all hazards. Of course, the great division of opinion
arises over the fact that the mechanism of the bill, in our
judgment, does much to destroy that relationship. While in
Washington, I had the good fortune to make the acquaintance
of some six senators who are members of the committee, and
thereby I was afforded opportunity for that direct, personal
presentation, which is not possible in the formal atmosphere
of committee rooms. I am confident that the results therefrom
will be entirely in keeping with your views.

(2) I am in receipt of a communication from the National
Physicians’ committee, confidential in character, proposing that
all of those who have worked against the Murray- Wagner-
Dingell bill, and who testified against it, attend a meeting in
St. Louis, Mo., in September of this year (this will be after
the formal hearings are closed) for the purpose of making a
final survey of the situation as it appears upon the record, and,
in the presence of conditions that have developed since the bill
was offered, to agree upon proposals for the further campaign
in opposition. You will recall that in January, 1946, I attended
National Physicians’ committee sessions in St. Louis at their
request, preparatory to our appearance in Washington before
the Senate committee on Education and Labor. There, I was
impressed by the very thorough manner in which that com-
mittee is carrying on its work, its daily, intimate association
with every possible development in the lobbies, committees and
halls of Congress, its check of every opposition move, and the
very evident unanimity of purpose of all members, a unanimity
that agrees on details as well as on major principles, and there-
fore does not split itself open in internal strife. The National
Physicians’ committee is doing its best to make arrangements
to add to the representation from each state, three or four
additional members from each state association, and I earnestly
hope these plans can be carried out, and that my successor in
office will have the full cooperation of members of the profes-
sion in Montana attending.

(3) The so-called "veterans’ problem” has come to the front
with unmistakable emphasis. Everywhere, the planners and so-
cializers are at work with grandiose schemes to take care of the
veterans and, undoubtedly, the great volume of care necessary
for them, to which they are rightfully entitled with the utmost
consideration and affection, has produced some necessity for
considering wavs and means for treatment of their numbers.
This very condition, however, is fraught with danger because
it contains the notion that the so-called "unorganized profes-
sion of medicine” cannot handle the problem. In this connec-
tion, I am going to ask the secretary to read at the end of my
report a letter which I have just received from the Veterans
Administration Office of Branch Medical Direction, Branch
No. 11, Exchange Building, Seattle, Washington, dated July
8, 1946, and signed "A. W. Schulz, M.D., Chief Out-Patient
Division.”

The fact that the nlan has been agreed to by the state med-
ical associations in Washington, Oregon and Idaho, as well as
Ohio, is encouraging, for it would seem that our brothers in

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the profession would not have joined therein to their detriment,
or to the detriment of the physician-patient personal relation-
ship. Their proposal emphasizes the retention, validity and op-
eration of that personal relationship, and if that can be assured,
I can see no objection to the adherence of our organization to
the plan.

(4) The Montana Physicians’ Service was organized and
commenced its function within the past year — indeed, within
the past six months, and while there has not been unanimity
in our association with regard to it, it has proceeded slowly and
carefully and is being better understood accordingly. Beyond
doubt, the activities of that organization will receive special
consideration at this meeting, particularly as respects the matter
of amending our constitution and by-laws to increase the tenure
of office of delegate and alternate members so that such mem-
bers of our association as are elected administrative members of
Montana Physicians’ Service and become trustees of the latter,
may serve for periods longer than one year.

(5) Expiration of corporate life: The official records of the
secretary of state indicate that the corporate life of Montana
State Medical association has expired and, in fact, expired in
the year 1923, some twenty-three years ago, and that this cor-
porate life has not been revived. If the Montana State Medical
association desires to continue in corporate form, this matter
must be given immediate and proper attention

(6) During the year past, the mobile X-ray unit has been
secured, placed in operation and is now frequently seen in the
various localities of our state, where its staff carries on its essen-
tial work in the field of tuberculosis, primarily. The association
may be gratified in the accomplishment of this project which it
endorsed, and I bespeak the most active cooperation of all doc-
tors, in their respective localities, whenever the unit shall visit
such localities.

During the past year, Dr. W. F. Cogswell retired as secre-
tary and, ex officio, executive officer of the state board of health.
He has been succeeded by Dr. B. K. Kilbourne. Dr. Cogswell’s
resignation broke a tie with this association which had endured
for more than 33 years and removed from active direction a
Montana doctor who worked unceasingly for the interests of
the profession and the public, and whose work never smacked
of the bureaucrat or bureaucracy. Dr. Kilbourne seems to have
the same attitude of mind, and we are happy to have him as
a successor to Dr. Cogswell upon the voluntary resignation of
the latter.

On Monday, January 6, 1947, there will convene in Helena
for the regular sixty-day session, a new legislative assembly fol-
lowing the election of November, 1946. This assembly will be
the thirtieth since the establishment of our state in 1889.
Among other things, this body will have before it the revision
of the codes of law of this state, and at such time the legis-
lative atmosphere is generally productive of change. Our asso-
ciation, and its legislative committee, must bear this in mind,
for such an atmosphere can operate not only to welcome new
ideas, some of them bizarre, but it can also operate to recog-
nize legislative changes that we deem desirable in the public
interests.

(At this point the secretary read the letter referred to bv
President Cooney and which follows under "National Physi-
cians’ Committee.”)

^NATIONAL PHYSICIANS’ COMMITTEE
Comments and Observations on Activities in Connection
with Washington Hearing

(Nationwide professional conference at St. Louis, Missouri,
Sept. 3, 4, 1946.)

(Statement of Dr. S. A. Cooney, President Montana State
Medical Association, July, 1945 - July, 1946)
Gentlemen of the Committee:

Agreeable to the invitation from the committee, I am glad
to make a brief report of my observations and activities in con-
nection with my appearance before the Senate committee on
Education and Labor on Senate Bill No. 1606, at Washington,
D. C., on May 28, 1946.

Let me say first and directly, that I was amazed when, as
president of the Montana State Medical association, my request
in February, 1946, that that association be heard on the pending
legislation, was answered by the committee on a mimeographed

form, with a flat denial, the excuse being that the calendar of
hearings would not permit additional presentations. Imme-
diately I telephoned Senator James E. Murray of Montana,
co-author of the legislation, whom I have known personally and
professionally for many years, and made some strong represen-
tations against what I considered an arbitrary stand, calculated
to deny full and fair consideration of opponents’ views. Sen-
ator Murray promised remedial action, and I am happy to say
that the Montana State Medical association and the medical
profession in Montana, received an invitation to send its repre-
sentatives, and it had the privilege of being the first state to
be so honored. I am convinced that no state association will be
denied a proper hearing, and I strongly urge each state to speak
for itself before the committee. I regard this as a necessity to
impress the committee of our grassroots origin.

As to the hearing proper:

(1) The committee heard all of us from Montana, in full
and with the utmost courtesy and consideration. I must stress
that, notwithstanding the known differences of opinion among
committee members, evident in many exchanges between them,
the atmosphere of the hearing was thoroughly friendly. We
were repeatedly questioned by committee members, particularly
Senator Donnell of Missouri and Senator Morse of Oregon,
both of whom had a clear appreciation of the measure. Not
because I am in St. Louis, but because Senator Donnell’s in-
cisive intelligence and judicial poise, require this expression—
I want to say Missouri is fortunate in having such a senator.
I am glad he shares our views, for his endorsement is added
evidence of their essential soundness.

(2) Following the hearing, I had opportunity to, and made
use of the opportunity personally to meet members of the com-
mittee. Let me observe here that I feel that personal contacts
of such character are absolutely invaluable — hence indispensable
in presentation of our cause. I have for more than thirty years
appeared before legislative committees (all that time a member
of the legislative committee of the Montana association) and
it is my conviction that more can be done to accomplish an
understanding by a personal visit, absent third persons, person-
alities and interruptions, than days and months of trench war-
fare in formal committee hearings. Such contacts break down
opposition. Formal hearings often solidify differences, but they
are a necessity in the national legislature.

(3) Without in any manner criticising, or assuming to criti-
cise the Washington representatives of N.P.C., or any who have
appeared for the profession in Washington in opposition to
S. 1606, and with deep appreciation for their labors, after inter-
viewing members of the committee, I am satisfied that the busy
doctors of this country have overlooked legitimate personal
lobbying of members of House and Senate, starting at home
and continuing in the capitol building. The floor team should
be increased in members if a continuous, vigorous and intelli-
gent representation in behalf of the private practice of medicine
in these United States is to be accomplished, and the direct
communication lines with "home” should be kept more active.
Members of the Senate and House are still the John Stumble-
foots of the home neighborhood.

(4) You know, of course, of the representations being cur-
rently made about N.P.C. by one Marjorie Shearon, Ph.D.,
so-called Research Analyst, Conference of the Minority, U. S.
Senate Office Building, Room 8-B, Washington, D. C. I do not
know her. I never saw her. But it is evident to me that she
is recognized by our friends in the Congress and I think it is
fairly inferable that she enjoys their patronage and support.
In my judgment, we had better look at ourselves in the light
of her remarks. When committee members listen to her, we
had better test the basis of her criticisms, and hear what our
own representatives have to say about them. American medicine
cannot afford a breach in its own ranks.

(5) I have been a lifelong member of the American Medical
association. It is a big organization, so big, that it sometimes
overlooks details. Members of our association in Montana
resent its failure to report the fact in the Journal that I was
its president and appeared for it in Washington. This is a
small thing in one sense, but when an association has but one
or two to voice its views, it wants the world to know that such
persons speak for it, otherwise it is, in truth, voiceless, as far
as the public record goes. I mention this here to emphasize

October, 1946

343

that we are but representatives, too, and the responsibility of
representatives of the medical profession, or any substantial
segment of it, is tremendous. It was evident to me, at least in
Senator Donnell’s questions, that he felt state organizations
were much more representative of the profession than national
organizations.

(6) It is my judgment that Senate 1606 is very much alive,
that its proponents are well entrenched, and that somehow,
somewhere, in some way, we have failed to bring the guns of
public opinion to bear upon it in an effective way. I believe
that opinion is against the measure. I want to hear what you
have to say.

Montana State Medical Association Roster-1946

MEMBERSHIP BY DISTRICTS

CASCADE COUNTY MEDICAL SOCIETY

Dr. Robert Holzberger, Pres

Great Falls

Dr. Thomas Keenan, V. Pres.

Great Falls

Dr. L. L. Maillet, Sec. . Great Falls

Allred, I. A. Great Falls

Adams, Ellis Great Falls

Anderson, C. E. Great Falls

Andrews, F. L. Great Falls

Bateman, H. W. ... Choteau

Bresee, C. J. Great Falls

Bulger, J. J. Great Falls

Crago, F. H. .... Great Falls

Craty, L. S. Fairfield

Davis, R. C. .... Great Falls

Durnin, R. B. Great Falls

Fuller, H. W. . ... Great Falls

Gibson, H. V. ...... Great Falls

Gleason, A. L. . Great Falls

Greaves, J. P. Great Falls

Hall, C. M. Great Falls

Hall, E. L. . _ Great Falls

Hildebrand, Eugene Great Falls

Hitchcock, E. D. Great Falls

Holzberger, R. J. Great Falls

Howard, L. L. Great Falls

Hurd, F. D. Great Falls

Itwin, J. H. Great Falls

Johnson, A. C. Great Falls

Keenan, F. E. Great Falls

Keenan, T. M. Great Falls

Larson, E. M. Great Falls

Layne, J. A. „ Great Falls

Little, C. F. Great Falls

Logan, P. E. Great Falls

Lord, B. E. ._ Great Falls

MacGregor, J. C. Great Falls

Magner, Charles Great Falls

Maillet, L. L. „ . Great Falls

McBurney, L. R. Great Falls

McGregor, H. J. Great Falls

McGregor, J. F. .... .......... Great Falls

McGregor, R. J. Great Falls

McPhail, F. L. Great Falls

McPhail, Malcolm Great Falls

Nagel, C. E. Great Falls

★Peterson, C. H. Great Falls

Richardson, R. B. Great Falls

Russell, Rosannah _. Fort Shaw

Schemm, F. R. Great Falls

Setzer, G. W. Malta

Shephard, H. C. Flat River, Mo.

Strain, Earle Great Falls

Templeton, C. V. .... Great Falls

Walker, Dora Great Falls

Walker, T. F. Great Falls

Waniata, F. K. Great Falls

Weisgerber, A. L. Great Falls

Williams, W. T. ... . Malta

CHOUTEAU COUNTY MEDICAL SOCIETY

Dr. E. L. Anderson, Pres. Ft. Benton Dr. E. L. Anderson, Sec.-Treas. Anderson, E. L. Ft. Benton

Ft. Benton Cooper, D. J. Big Sandy

Dr. J. J. Elliott, Pres. Lewistown

Dr. E. M. Gans, V. Pres Harlowton

Dr. F. F. Attix, Sec.-Treas. Lewistown

Alexander, J. L. Winnett

Attix, F. F. Lewistown

★ Dismore, A. B. Stanford

FERGUS COUNTY MEDICAL SOCIETY

Eck, R. L. Lewistown

Elliott, J. J. . . . Lewistown

Freed, Hazel Stanford

Gans, E. M. Harlowton

Gans, E. W. Harlowton

Gans, P. J. Lewistown

Herring, J. H. Lewistown

Johnson, R. G. Harlowton

Mueller, J. A. Lewistown

Porter, E. S. ...... Lewistown

Shubert, J. W. Lewistown

Welden, E. A. Lewistown

FLATHEAD COUNTY MEDICAL SOCIETY

Kalispell

Cairns, J. M.

Libby

Leitch, Neil

Dr. T. B. Moore, Jr., V. Pres

Kalispell

Clark, C. A.

Eureka

Moore, T. B., Jr.

Dr. H. D. Huggins, Sec

. Kalispell

Cockrell, E. P

Kalispell

Paul, F. W.

Dr. R. L. Towne, Treas

. Kalispell

Conway, W. Q. ....
★ Delaney, J. R.

Kalispell

Ross, F. B.

Simons, J. B.

Dimon, John

Poison

Stewart, R. M. ..

Boyd, Edith

Whitefish

Dodge, A. A.
Griffis, L. G.

Kalispell

Taylor, W. W.
Towne, R. L.

Kalispell

Whitefish

Kalispell

★ Brown, J. W

Huggins, H. D. ....

Kalispell

Weede, V. A.

Burns, M. O.

Kalispell

Lees, A. T.

Whitefish

Wright, G. B.

GALLATIN COUNTY

MEDICAL SOCIETY

Dr. W. S. Bole, Pres.

Bozeman

★Craft, C. B.

Bozeman

Scherer, R. G.

Dr. P. L. Eneboe, V. Pres.

Bozeman

Eneboe, Paul

Bozeman

Seerley, C. C.

Dr. R. A. Williams, Sec

Bozeman

Grigg, E. R.
Heetderks, B. J.

Bozeman

Seitz, R. E.

Sigler, R. R.
Smith, C. S.

Bole. W. S

★ Kearns, E. J.

Bozeman

Bradbury, J. T. .... Willow Creek

Keeton, R. G.

Bozeman

Whitehead, C. E.

Brewer, A. D.

Bozeman

Sabo, F. I

Bozeman

Williams, R. A. .

. Kalispell
Kalispell
. Kalispell
. Kalispell
Whitefish
Whitefish
Whitefish
Kalispell
Kalispell
. Kalispell

Bozeman

Dr. W. F. Hamilton, Pres. Havre

Dr. G. A. Jestrab, V. Pres. _ . Havre
Dr. Chester Lawson, Sec Havre

Almas, D. J. Chinook

HILL COUNTY MEDICAL SOCIETY
Aubin, F. W. Havre

Benke, R. A. Kalispell

Forester, W. L. _. Havre

Hamilton, W. F. Havre

Hoon, A. S. Chinook

Houtz, C. S. Havre

★Brooke, J. M.
French, E. J. ..

LAKE COUNTY MEDICAL SOCIETY (Discontinued

Ronan ★Lipow, E G. Ronan

, Ronan Tanglin, W. G. Poison

Jestrab, G. A.

Havre

Lacey, W. A. ..

Havre

Lawson, Chester

Havre

MacKenzie, D. S.

Havre

MacKenzie, D. S , Jr. ..

Havre

McCannel, W. A.

Chinook

temporarily)

Teel, H. M.

Poison

Venneman, F. W.

St. Ignatius

344

The Journal-Lancet

LEWIS & CLARK COUNTY MEDICAL SOCIETY

Dr. E. L. Gallivan, Pres. Helena

Dr. E. H. Lindstrom, V. Pres. Helena

Dr. R. M. Campbell, Sec Helena

Bayles, R. G. Townsend

Berg, D. T. Helena

Campbell, Robert .... Helena

Cashmore, W. F. Helena

Cooney, S. A. Helena

★Farner, L. M. .... Helena

Flinn, J. M. Helena

Gallivan, E. L. Helena

Hawkins, T. L. Helena

Kilbourne, B. K. Helena

Klein, O. G. Helena

Levitt, Louis _ Boulder

Lindstrom, E. H. Helena

McCabe, j. J. Helena

McElwee, W. R. White Sulph. Springs

Mears, Claude Helena

Monserrate, D. N. Helena

Moore, O. M. Helena

Morgan, R. M. Helena

Morris, R. W Helena

Nash, F. P Townsend

Shale, R. J. Helena

★Shearer, B. C. Helena

MADISON COUNTY MEDICAL SOCIETY

Dr. L. R. Packard, Pres Whitehall Burns, W. J. Sheridan Dyer, R. H.

Dr. R. H. Dyer, Sec.-Treas Sheridan ★Clancy, John Ennis Farnsworth, R. B.

Packard, L. R.

MOUNT

Dr. J. J. Malee, Pres Anaconda

Dr. B. L. Pampel, V. Pres

Warm Springs
Dr. G. M. Donich, Sec Anaconda

Anderson, G. A. Deer Lodge

Donich, G. M. Anaconda

POWELL COUNTY MEDICAL SOCIETY

Dunlap, L. G. Anaconda O’Rourke, J. L.

Holmes, Gladys V. .... Warm Springs Pampel, B. L.

Kargacin, T. J. Anaconda Place, B. A.

Knight, A. C. Philipsburg Terrill, F. I.

Long, W. E. Anaconda Trobough, G. E.

Malee, J. J. Anaconda Tyler, K. A.

Moffett, G. J. Deer Lodge Unmack, F. L.

MUSSELSHELL COUNTY MEDICAL SOCIETY

Sheridan
Virginia City
Whitehall

Anaconda

Warm Springs
Warm Springs

Galen

Anaconda

Galen

Deer Lodge

Dr. S. A. Crouse, Pres. Roundup Bennett, A. A. Roundup Lewis, G. A. Roundup

Dr. A. A. Bennett, V. Pres. Roundup Crouse, S. A. Roundup O’Neill, R. T. Roundup

Dr. G. A. Lewis, Sec. Roundup Fouts, E. R. Ryegate

NORTHCENTRAL MONTANA MEDICAL SOCIETY

Dr. S. D. Whetstone, Pres. Cut Bank

Dr. N. A. Olsen, V. Pres Cut Bank

Dr. W. L. Dubois, Sec.-Treas. Conrad
Bosshardt, O. A Ontario, Calif.

Cannon, P. S. Conrad

Dubois, W. L. Conrad

Elliott, L. L. Cut Bank

Neraal, P. O. ... Cut Bank

Olsen, N. A. Cut Bank

Paterson, W. F. . Conrad

Robinson, W. C. .. . Shelby

Whetstone, S. D. .... Cut Bank

NORTHEASTERN MONTANA MEDICAL SOCIETY

Dr. O. G. Benson, Pres. Plentywood
Dr. R. E. Ryde, Sec.-Treas Glasgow

Agneberg, N. O. Glasgow

Benson, O. G. Plentywood

Cockrell, T. L. Hinsdale

Knapp, R. D. Wolf Point

Knierim, F. M. Glasgow

Krogstad. L. T, Wolf Point

Larson, C. B. Glasgow

★Mittleman, E J. Wolf Point

Morrow, T. M. Scobey

★ Peterson, W. M. Plentywood

Pronin, Arthur Plentywood

Ryde, R. E. Glasgow

★Schweizer, H. W. Ft. Worden, Wash.
Smith, A. N. Glasgow

PARK-SWEETGRASS MEDICAL SOCIETY

Dr. J. A. Pearson, Pres Livingston

Dr. W. E. Harris, V. Pres. Livingston
Dr. E. M. Larson, Sec.-Tr Livingston

Baskett, L. W. Big Timber

Claiborn, D. R Big Timber

Cogswell, W. F. .. Helena

Larson, Eloise M. Livingston

Leard, S. E. . _ Livingston

Lueck, A. M. .... Livingston

March, J. A. Choteau

Pearson, J. A. Livingston

Townsend, G. A. Emigrant

Walker, R. E. Livingston

Windsor, G. A. Livingston

SILVER BOW COUNTY MEDICAL SOCIETY

Dr. P. T. Spurck, Pres.

Dr. D. A. Atkins, V. Pres.
Dr. S. V. Wilking, Sec.

Dr. C. R. Canty, Treas

Atkins, D. A.
Brancamp, J. H.

Canty, C. R.

Casebeer, H. L.
Casebeer, R. L.
Colman, J. K. ...
Frisbee, J. B.

Garvey, J. E.

Gillespie, D. L.
Gregg, H. W.
Hill, R. J.

Butte

Horst, C. H.

Butte

O’Keife, N. J.

Butte

James, H. H.

Butte

Pemberton, C. W.

Butte

Kane, J. J.

Butte

Peterson, R. F.

Butte

Kane, P. E.

Butte

Poindexter, F. M.

Dillon

Kane, R. C.

Butte

Rodes, C. B.

Butte

Karsted, A.

Butte

Routledge, G. L.

Dillon

Butte

Kroeze, R G.

Butte

Saam, T. W. .

Butte

Lapierre, J. C.

Butte

Lhotka, J. F.

Butte

Shields, J. C.

Butte

MacPherson, G. T.

Butte

Sievers, A. R

Butte

Matthews, Vida J.

Sievers, J. R. E.

Butte

McGill, Caroline

Butte

Spurck, P. T.

Butte

Dillon

Monahan, R. C.

Butte

Stephan, W. H.

... Dillon

Butte

Mondloch, J. L.

Butte

Ungherini, V. O.

Butte

Whitehall

Odgers, S. L.

Butte

Wilking, S. V.

Butte

SOUTHEASTERN MONTANA MEDICAL SOCIETY

Dr. J. R. Thompson, Pres Miles city

Dr. R. D. Harper, V. Pres. Sidney
Dr. Elna M. Howard, Sec. Miles City

Beagle, J. S.
Benson, R. D.
Blakemore, W. H.
Bridenstine, I. J.
Craig, J. W.

★ Dale, E.

Danskin, M. G.
Dion, R. H.

Farrand, B. C.

Garberson, J. H.

Sidney
Sidney
Baker
Miles City
Circle
Wibaux
Glendive
Glendive
Jordan
Miles City

Harlowe, H. D. ...
Harper, R. D.
Haywood, Guy
Hogebohm, C. F.
Howard, Elna M.
Huene, H. J.

★ 1 ,emon, R. G.
Lindeberg, Sadie B.

Low, John E.

Morrill, R. A.
Noonan, E. F.
Olson, S. A.
Parsons, H. H.

Miles City Polk, R. W. Miles City

Sidney Pratt, S. C. .... Miles City

Forsyth Randall, R. R. Miles City

Baker Robbins, B. L. ....... Glendive

Miles City Rowen, E. H. Miles City

Forsyth Rundle, B. S. Circle

Glendive Sandy, B. B. Ekalaka

Miles City Shillington, M. A. Glendive

Sidney Spicher, R. W. Terry

Sidney Tarbox, B. R. Forsyth

Wibaux Thompson, J. R Miles City

Glendive Weeks, S. A. Baker

Sidney Winter, M. D. . Miles City

October, 1946

345

WESTERN MONTANA MEDICAL SOCIETY

Dr. E. S. Murphy, Pres. Missoula

Dr. C. F. Honeycutt, V. Pres. Missoula

Dr. F. H. Lowe, Sec-Treas Missoula

Aiderson. L. R. . Missoula

Blegen, H. M. Missoula

Bourdeau, C. L. .. Missoula

kBourdeau, E. J. Missoula

Boyer, Esther L. Missoula

Brewer, L. W. Missoula

Doyle, W. Superior

kDuffalo, J. A. Missoula

Farabaugh, C. L. Missoula

kFattic, G. F. Hot Springs

kFerret, A. Missoula

Foss, A. R. Missoula

Fredrickson, C. H. Missoula Murphy, E. S.

George, E. K. Missoula ★Murphy, J. E.

★ Gordon. D. A. Hamilton Nelson, J. M.

Haas, A. T. Missoula Ohlmacher, J. P.

Hall, H. J. „ Missoula Pease, F. D.

Harris, W. E. Missoula Peterson, R. L.

Hayward, Herbert Hamilton Preston, S. N. ...

★Hesdorffer, M. B. ...... .... Missoula Rew, A. W.

Holmes, J. T. Missoula Ritchey, J. P.

Honeycutt, C. F. Missoula Sale, G. G.

Keys, R. W. Missoula ★Svore, C. R.

Kintner, A. R. Missoula Tefft, C. C.

★ Koessler, H. H. Missoula Thornton, C. R.

Lowe, F. H. Missoula Trenough, S. M.

Marshall, W. J. Missoula Weber, R. D. ....

McPhail, W. N. . Missoula Wirth, R. E.

Morrison, W. F. . Missoula Yuhas, J. L.

YELLOWSTONE VALLEY MEDICAL SOCIETY

Dr. H. O. Drew, Pres. Billings

Dr. J. C. Powers, V. Pres Billings

Dr. H. E. McIntyre, Sec. Billings

Dr. J. J. Hammerel, Treas. Billings

Adams, E. M. Red Lodge

Allard, L. W. Billings

Anderson, M. O. Hardin

Beltzer, C. E Washoe

Benson, R. E. . Billings

5 Benson, T. J. Fromberg

Biehn, R. H. Billings

Blackstone, A. V. ... Absarokee

Bridenbaugh, J. H. ...... Billings

Brogan, R. E. Billings

Caraway, H. T. Billings

I Carey, W. R . Rosebud, S. D.

Chappie, R. R. . . . Billings

DeMers, J. J. Huntley

Drew, H O. Billings

Dunkle, Frank Billings

Farr, E. M Billings

Feree, V. D. Bridger

Fisher, M. L. Hardin

Gerdes, Maude M. Billings

Gordon, Wayne Billings

Graham, J. H. Billings

Griffin, P. E. Billings

Hagmann, E. A. Billings

Hall, E. C. Laurel

Hammerel, A. L. Billings

Hammerel, J. J. Billings

★Hayes, J. D. Mammoth Hot Springs,
Yellowstone Park

Hodges, D. E. . Billings

Hynes, J. E. Billings

Irwin, C. E. ... - Billings

★Knese, L. A. Yellowstone Co.

Kronmiller, L. H. Billings

Labbitt, L. H. Hardin

MacDonald, D. J. . Billings

McIntyre, H. E. Billings

Morgan, H. G. Red Lodge

Morledge, R. V.
Morrison, J. D.
Morrison, W. R.
Movius, A. J.
Movius, A. J., Jr.
Movius, W. R.

Nelson, C. H.

Neville, J. V. _.

Oleinik, J. M. ....

Powers, J. C.

Rathman, O. C.
Richards, W. G.
Russell, L. G.

Shaw, J. A

Soltero, J. R.
Stripp, A. E.
Unsell, D. H.

Vye, T. R.
Weedman, W. F.
Werner, S. L.
Wernham, J. I.

Missoula

Hamilton

Missoula

Thompson Falls

Missoula

Somers

Hamilton

Missoula

Billings
Billings
Billings
Billings
Billings
Billings
Billings
Columbus
Red Lodge
. Billings
Billings
Billings
Billings
Billings
Billings
.... Billings

Billings

Laurel

Billings

★Member in the Armed Forces of the United States.

Alphabetical Roster

Montana State Medical Association-1946

Adams, E. M.

Red Lodge

Benson, T. J.

Fromberg

Adams, Ellis W. ...

Great Falls

Berg, D. T.

Helena

Campbell, Robert

Helena

Agneberg, N. O.

... Glasgow

Biehn, R. H.

Billings

Cannon, P. S.

Conrad

Aiderson. 1 R.

Missoula

Blackstone, A. V.

Absarokee

Canty, C. R.

Alexander, J. L.

(Life member)
Allard, L. W.

Winnett

Blakemore, W. H.
Blegen, H. M.

Baker

Missoula

Caraway, H. T.
Carey, W. R.

... Billings

. ... Rosebud, S. D.

. Billings

Bole, W. S.

1 Allred, I. A.

.. Great Falls

★ Borkon, M.

Whitefish

Casebeer, R. L.

Almas, D. J.

Chinook

Bourdeau, C. L.
★Bourdeau, E. J.

Missoula

Cashmore, W. F.

Anderson, C. E.

Great Falls

. Missoula

Chappie, R. R. ...

Billings

Anderson, fc. L.

Et. Benton

Boyer, Esther L.
Bradbury, J. T.

(Honorary member)

Missoula

Claiborn, D. R.

Billings

Anderson, G. A. ....
Anderson, M. O.

Deer Lodge

Hardin

. Willow Creek

★Clancy, John
Clark, C. A. ._

- — . Ennis

Eureka

Andrews, F. L.

(jreat Balls

Brancamp, J. H

Butte

Atkins, D. A. ..

Butte

Brassett, A. J.

Kalispell

Cockrell, T. L. ....

Hinsdale

Attix, F. F.
Aubin, F. W.

Lewistown

Havre

Bresee, C. J.

Brewer, A. D.

Great Falls
— . ... Bozeman

Cogswell, W. F. ....
(Life member)

Helena

Baskett, L. W.

Big limber

Brewer, L. W.

Missoula

Colman, J K.

Butte

Bateman, H. W.

Choteau

Bridenbaugh, J. H.

Billings

Conway, W. Q.

.... Kalispell

Bayles, R G.

Townsend

Bridenstine, I. J.

Miles City

Cooney, S. A.

.... Helena

Beagle, J. S.
Beltzer, C. E. ._

Sidney

Brogan, R. E.

Billings

Cooper, D. J.

Big Sandy

Washoe

★Brooke, J. M.

Ronan

★Craft, C. B. .

Benke, R. A.

Chester

★ Brown, J. W.

.... Whitefish

Craig, J W.

Circle

Bennett, A. A.

Roundup

Bulger, James J.

Burns, M. O

— Great Falls

Crago, F. H.

Great Falls

Benson, O. G.

Plentywood

Kalispell

Crary, L. S.

Fairfield

Benson, R D.

.... Sidney

Burns, W. J.

Sheridan

Crouse, S. A.

Roundup

Benson, K. E.

Bosshardt, O. A

Ontario, Calif.

★ Dale, E.

... Wibaux

346

The Journal-Lancet

Danskin, M. G. ..

Glendive

Hildebrand, E.

Great Falls

Malee, J. J.

Anaconda

Great Falls

Hill, R. J.

Whitehall

★ Delaney, J. R. .

Kalispell

Hitchcock, E. D,

Great Falls

Marshall', W. J. ...

Missoula

Huntley

Hodges, D. E.

Billings

Poison

Hogebohm, C. F.

Baker

Dion, R. H.

Glendive

Holmes, Gladys V

Warm Springs

McCabe, J. J.

Helena

Stanford

Holmes, J. T.

. Missoula

McCannel W A

Kalispell

Holzberger, R. J.

Great Falls

MrElwee. W R

Donich, G. M.

__ Anaconda

Honeycutt, C. F.

Missoula

White Sulphur Springs

Doyle, W. J.

Superior

Hoon, A. S.

Chinook

McGill, Caroline

Butte

Billings

Horst, C. H.

Butte

DuBois, W. L.

Conrad

Houtz, C. S. __

Havre

McGregor, J. F.

Great Falls

★Duffalo, J. A.

Missoula

Howard, Elna M.

Miles City

McGregor, R. J.

Great Falls

Billings

Howard, L L.

Great Falls

McMahon, E. S. ..

Dunlap, L. G.

. . Anaconda

Huene, H. J.

Huggins, H. D.

Forsyth

McPhail, F. L.

Great Falls

Durnin, R. B.

Great Falls

Kalispell

McPhail, Malcolm ...

Great Falls

Sheridan

Hurd, F. D.

Great Falls

McPhail W N

__ Lewistown

Hynes, J. E.

Billings

Elliott, J. J.

Lewistown

Irwin, C. E.

Billings

★ Mittleman, E. J.

Wolf Point

Cut Bank

Irwin, J, H.

Great Falls

Bozeman

James, H. H.

Butte

Farabaugh, C. L.

Missoula

Jestrab, G. A. ....

... Havre

Monserrate, D. N. .

Helena

★Farner, L. M.

Helena

Johnson, A. C.

Great Falls

Moore, O. M.

. .... Helena

Farnsworth, R. B,

Virginia City

Johnson, R. G.

Harlowton

Moore, T. B., Jr. ....

Kalispell

Billings

Kane, Joseph J

Butte

_ Jordan

Kane, P. E.

Butte

Hot Springs

Kane, R. C.

Butte

Ferree, V. D.

Kalispell

Kargacin, T. J.

Anaconda

Morr.il, R. A.

Sidney

Missoula

Karsted, A. J.

Butte

Morris, R W.

Hardin

★ Kearns, E. J.

Bozeman

Helena

Keenan, F. E.

Great Falls

Morrison, W. F.

Forster, W L.

Havre

Keenan, Thomas M

Great Falls

Morrison, W. R.

Billings

Missoula

Keeton, R. G.

Bozeman

Morrow, Thomas M.
Movius, A. J. ...

Ryegate

Keys, R. W.

Missoula

Fredrickson, C. H.

_ Missoula

Kilbourne, B, K.

Helena

Movius, A. J., Jr.

Billings

Stanford

Kintner, A. R. __ ... .

Missoula

Movius, Wm, R.

Ronan

Klein, O. G

Helena

Mueller, James A.

(Life member)

Knapp, R. D.

Wolf Point

Murphy, E. S. ...

Missoula

Frisbee, J. B,

Butte

★ Knese, L. A. Yellowstone Valley

★ Murphy, ). E.

Flathead County

Fuller H W.

Great Falls

Knierim, F. M. . __ . __

Glasgow

Nagel, C. E.

Gallivan, E. L.

Helena

Knight, A. C.

Philipsburg

Nelson, C. H. .

Billings

Harlowton

★ Koessler, H. H

Missoula

Nelson, J. M.

★Gans E. W.

Harlowton

Kroeze, R

Butte

Neraal, P, O.

Gans, Paul J.

Lewistown

Krogstad, L. T.

Wolf Point

Neville, J. V. ..

Columbus

Garberson, 1 FL

Miles City

Kronmiller, L. H.

Billings

Noonan, E. F.

.... Wibaux

Butte

Labbitt, L. H

Hardin

Odgers, S. L

Missoula

Lacey, W. A.

Havre

Ohlmacher, J P.

Gerdes, Maude M.
Gibson, H. V.

Billings

Lapierre, J. C

Butte

O’Keefe, N. J.

Great Falls

Larson, Eloise M.

Livingston

Oleinek, John M.

Red Lodge

Butte

Larson, C. B.

Glasgow

Olsen, N. A.

Gleason, A. L.

Great Falls

Larson, E. M. ....

Great Falls

Olson, S. A.

Glendive

Hamilton

Lawson, C. W.

Havre

O'Neill, R. T.

Gordon, Wayne

Billings

Layne, J. A.

Great Falls

O’Rourke, J. L.

Anaconda

Billings

Leard. S. E.

Livingston

Packard, L. R.

Whitehall

Greaves, J. P.

Great Falls

(Life member)

Pampel, B L.

Warm Springs

Gregg, H W.

.. Butte

Lees, A. T.

Whitefish

Parsons. H H

Billings

Leitch, Neil

Kalispell

Paterson, W. F.

... Kalispell

★ Lemon, R. G.

Glendive

Paul, F. W.

Levitt, L

Boulder

Pearson, J. A.

Missoula

Lewis, G. A.

Roundup

Pease, F. D.

Hagmann, E, A.
Hall, C. M.

Billings

Lhotka, J. F.

Butte

Pemberton, C. W. ...

Great Falls

Lindeberg, Sadie B.

Miles City

★ Peterson, C. H.

Great Falls

Hall, E. C.

Lindstrom, E H

Helena

Peterson, R. F.

Hall, E. L.

Great Falls

★ Lipow, E. G.

Little, C. F.

Ronan

Peterson, R. L.

Hamilton

Hall, H J.

Missoula

.... Great Falls

★ Peterson, W. M.

Plentywood

Hamilton, W. F.

Havre

Logan, P. E.

Great Falls

Place, B. A.
Poindexter, F. M. .

Warm Springs

Long, W. E

Anaconda

Billings

Lord, B. E.

Great Falls

Polk, R. W.

Miles City

Harlowe, H. D.
Harper, R D.

Sidney

Porter, E. S.

.. .. Sidney

Lowe, F. H.

Missoula

(Life member)

Harris, W. E.

Lueck, A, M

Livingston

Powers, J. C.

MacDonald, D. J.

Billings

Pratt, S. C.

★ Hayes, J. D Mammoth Hot Springs,

MacGregor, J. C.

.... Great Falls

Preston, S. N.

Missoula

Yellowstone Park

MacIntyre, H. E.

Billings

Pronin, Arthur

Plentywood

Hayward, H C.

Hamilton

MacKenzie, D. S.

Havre

Randall, R R.

Miles City

Haywood, Guy T.

Forsyth

MacKenzie, D. S., Jr.

Havre

Rathman, O. C.

Billings

Heetderks, B. J.

Bozeman

MacPherson, G. T.

Magner, Charles

Maillet, L. L

Butte

Rew, A. W.

Thompson Falls

Herring, J. H.

Lewistown

Great Falls

(Life member)

★Hesdorffer, M. B

Missoula

Great Falls

Richards, W. G.

Billings

October, 1946

347

Richardson, R. B. Great Falls Shields, J. C. Butte

Ritchey, J. P. Missoula Shillington, M. A. Glendive

Robbins, B. L. Glendive Sievers, A. R. Butte

Robinson, W. C. Shelby Sievers, J. R. E. Butte

Rodes, C. B. Butte Sigler, R. R. Bozeman

Ross, F. B. Kalispell Simons, J. B. Whitefish

Routledge, G. L. Dillon Smith, A. N. Glasgow

Rowen, E. H. Miles City Smith, C. S. Bozeman

Rundle, B. S. ... Circle Soltero, J. R. Billings

Russell, L. G. .. Billings Spicher, R. W. Terry

Russell, Rosannah Ft. Shaw Spurck, P. T. Butte

(Honorary member) Stanchfield, H. .... Dillon

Ryde, R. E. Glasgow Stephan, W. H. Dillon

Saam, T. W. Butte Stewart, R. M. Whitefish

j Sabo, F. I. . Bozeman Strain, Earle Great Falls

| Sale, G. G Missoula Stripp, A. E. Billings

Sandy, B. B. Ekalaka ★Svore, C. R. Somers

Schemm, F. R. Great Falls Tanglin, W. G. Poison

Scherer, R. G. Bozeman Tarbox, B. R Forsyth

Schubert, J. W. .. Hardin Taylor, W. W. ... Whitefish

Schwartz, Harold Butte Teel, H. M. Poison

★Schweizer, H. W. .. Poplar Tefft, C. C. ... ... Hamilton

Seerley, C. C. Bozeman Templeton, C. V. Great Falls

Seitz, R. E. .. Bozeman Terrill, F. I. ... Galen

Setzer, G. W. Malta Thompson, J. R. Miles City

Shale, R. J. Helena Thornton, C. R. Missoula

Shaw, J. A. Billings Towne, R. L. Kalispell

★Shearer, B. C. Helena Townsend, G. A. Livingston

Shephard, H. C. Flat River, Mo. Trenough, S. M. Missoula

★Member in the Armed Forces of the United States.

Trobough, G. E.
Tyler, K. A.
Ungherini, V. O. __
Unmack, F. L.
Unsell, David H.
★Vasco, J. R.
Vennemann, F. W.
Vye, T. R.

Walker, Dora V. H
Walker, R. E.
Walker, Thomas F.
Waniata, F. K.
Weber, R. D
Weed, V. A.

Weedman, W. F.

Weeks, S. A.
Weisgerber, A. L.
Welden, E. A.
Werner, S. L
Wernham, J. I. ...
Whetstone, S. D.
Whitehead, C. E.
Wilking, S. V.
Williams, R. A.
Williams, W. T.
Windsor, G. A. ...
Winter, M. D.

Wirth, R. E.

Wright, G. B.

Yuhas, J. L.

.. Anaconda
Galen
Butte
Deer Lodge
Billings
Great Falls
St. Ignatius
Laurel
Great Falls
Livingston
Great Falls
Great Falls
... Missoula
.. Kalispell
... Billings

Baker

Great Falls
Lewistown
... Billings
Billings
. Cut Bank
Bozeman
Butte
Bozeman
Malta
Livingston
Miles City
.. Missoula
Kalispell
.. Missoula

REPORT OF THE FIFTH ANNUAL MEETING OF THE WOMAN’S AUXILIARY TO THE
MONTANA STATE MEDICAL ASSOCIATION

Officers

President Mrs. Roy V. Morledge, Billings

President-elect Mrs. Harold Schwartz, Butte

1st Vice President Mrs. A. C. Knight, Philipsburg

2nd Vice President Mrs. J. P. Greaves, Great Falls

Treasurer Mrs. A. A. Dodge, Kalispell

Secretary Mrs. H. T. Caraway, Billings

I Directors

2 Year Term Mrs. Clyde Frederickson, Missoula

2 Year Term Mrs. R. J. Holzberger, Great Falls

1 Year Term ..... Mrs. F. F. Attix, Lewistown

The fifth annual meeting of the Woman’s Auxiliary to the
Montana State Medical Association was called to order by the
president, Mrs. I. J. Bridenstine, in Great Falls, July 19, 1946.
Mrs. H. V. Gibson, President of the Cascade Auxiliary, wel-
comed the members of the auxiliary to Great Falls. The report
of the committee on approval of minutes of the last annual
meeting held in Helena, July 15, 1945, was given, and the
minutes were read. Annual reports of the state officers, com-
mittee chairmen, and county presidents were presented to the
assembly. Guest speakers were Mrs. Mildred W. Schemm of
Great Falls, Miss Elizabeth Baker of Glendive, Dr. S. A.
Cooney of Helena, Dr. M. A. Shillington of Glendive, and
Dr. J. P. Ritchey of Missoula.

JOURNAL

LANCET

Serves the

MINNESOTA, NORTH DAKOTA,

Medical Profession of

SOUTH DAKOTA and MONTANA

ADVISORY COUNCIL

North Dakota State Medical Assn.
Dr. A. E. Spear, Pres.

Dr. Philip G. Arzt, Pres.-Elect
Dr. L. W. Larson, Secy.

Dr. W. W. Wood, Treas.

North Dakota Society of
Obstetrics and Gynecology
Dr. Paul Freise, Pres.

Dr. G. Wilson Hunter, Vice Pres.
Dr. F. A. DeCesare, Secy .-Treas.

Minneapolis Academy of Medicine
Dr. Russell W. Morse, Pres.

Dr. Paul F. Dwan, Vice Pres.

Dr. J. C. Miller, Secy.

Dr. Ragnvald S. Ylvisaker, T reas.
Dr. Henry E. Hoffert, Recorder

South Dakota State Medical Assn.
Dr. F. S. Howe, Pres.

Dr. H. R. Brown, Pres.-Elect
Dr. J. L. Calene, Vice Pres.

Dr. Roland G. Mayer, Secy. -Treas.

South Dakota Public Health Assn.
Dr. J. M. Butler, Pres.

Dr. C. E. Sherwood, Vice Pres.

Dr. Gilbert Cottam, Secy .-Treas.

Sioux Valley Medical Assn.

Dr. D. S. Baughman, Pres.

Dr. Will Donahoe, Vice Pres.

Dr. R. H. McBride, Secy.

Dr. Frank Winkler, Treas.

BOARD OF EDITORS

Dr. J. A. Myers, Chairman

Montana State Medical Assn.

Dr. M. A. Shillington, Pres.

Dr. L. W. Allard, Pres.-Elect
Dr. H. T. Caraway, Secy.-T reas.

Northwestern Pediatric Society
Dr. G. B. Logan, Pres.

Dr. Geo. Kimmel, Vice Pres.

Dr. Northrop Beach, Secy.-T reas.

Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.

Dr. R. C. Webb, Secy. -Treas.

American Student Health Assn.

Dr. Ralph I. Canuteson, Pres.

Dr. Laurence Chenoweth, Vice Pres.
Dr. G. T. Blydenburgh, Secy .-Treas.

Dr. J . O. Arnson
Dr. A. B. Baker
Dr. D. S. Baughman
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W. A. Fansler

Dr. A. R. Foss
Dr. J ames M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. J . Mabee

Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C. H. Nelson
Dr. N. J . Nessa
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. C. E. Sherwood

Dr. M. A. Shillington
Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J. H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. S. E. Sweitzer

Dr. W. H. Thompson
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin,
Secretary

LANCET PUBLISHING CO., Publishers, 84 South Tenth St., Minneapolis 2, Minnesota
Minneapolis, Minnesota, October, 1946

"FUNCTIONAL HEART MURMURS”
UNSATISFACTORY TERM

When we speak of an organic disease, we usually think
of one in which there is anatomical change in some of
the tissues or organs of the body. Such change may not
always be demonstrable during life but we are neverthe-
less justified in making the statement because experience
has taught us that the post mortem examinations disclose
explanatory findings. Because of painstaking studies,
either before or after death, based upon the feeling that
there should be some discernible tissue change to account
for the manifestations of every patient’s complaint, some
afflictions, formerly classified as functional, have been
transferred to the organic group. When no local change
is present, we have learned to search more remote regions
for a focal or reflex explanation.

It is even more difficult to make an unalterable diag-
nosis of a functional disease. This term is used as it is
still necessary to distinguish between purely pathological
physiology and disease due to anatomical lesions, but it

is not particularly popular. Even in regard to symptoms,
there is a growing tendency to discard its use. We
rarely hear anyone speak of a functional heart murmur.
It is generally known that the most common murmur
to be heard in the heart is the systolic in left second
interspace which, when properly assessed, is innocent
as it is usually a normal physiological phenomenon
caused by the blood rushing into the distensory pulmo-
nary artery close to the chest wall at the time of expira-
tion. The cardio-respiratory murmur due to air rushing
into the lungs is no longer afflicted with the name func-
tional as this term has no diagnostic significance. Mur-
murs of this type are described by giving location, char-
acter, transmission, constancy or inconstancy, and posi-
tion in the cycle as are the well recognized murmurs. If
some additional name seems necessary, then physiologi-
cal, cardio-respiratory, or even unexplained or unimpor-
tant, may be used. We speak of cardiac neurosis as a
functional disorder of the heart although, strictly speak-
ing, it is rather a disease of the nervous mechanism.

A. E. H.

348

all the alkaloids of opium in highly purified, water-soluble form, suitable for

injection. Thousands of physicians have found Pantopon a dependable

preparation in all cases requiring opiates. Pantopon 'Roche' is available in

ampuls, hypodermic and oral tablets, and in powder form.

HOFFMANN-LA ROCHE, INC., ROCHE PARK, NUTLEY 10. N. J.

350

The Journal-Lancet

THE PASSING OF THE FAMILY DOCTOR

Mountin showed that as early as 1938, not only were
rural practitioners decreasing in numbers, but they were
older than their urban confreres. His study indicated
both that fewer graduates were locating in smaller towns,
and that many of the younger physicians who originally
located in rural areas were migrating to the larger cities.

In the June 1946 issue of the Journal Lancet, it
was shown that North Dakota with 641,935 population
has 363 physicians; South Dakota with 642,961 popula-
tion has 334 physicians; Montana with 559,456 popula-
tion has 361 physicians; and Minnesota with 2,792,300
population has 2,565 physicians.

Smith, Executive Secretary of the Nebraska State
Medical Association, in the July issue of the Wisconsin
Medical Journal said, "As it looks from Nebraska, the
medical profession has an unrecognized number one prob-
lem— the threatened extinction of the general practi-
tioner. . . . The seriousness of this situation is more evi-
dent in the rural areas and smaller towns. Older men are
retiring or are removed by death, and are not being re-
placed by younger men. This is a blow at the very
foundation of medicine.”

Contributing to the scarcity of physicians rurally and
their concentration in the larger cities is the trend toward
specialization. In 1941, it was found that of 175,382
physicians in the United States, 140,000 engage in pri-
vate practice; and of this latter number 36,483 limit
their practice to various specialties. In 1946, it was found
that 30 per cent of practicing physicians are full special-
ists and 20 per cent are partial specialists, leaving only
50 per cent of practicing physicians in general practice.

The American system of medicine always has had the
general practitioner as the very hub of its machinery.
Family doctors are an essential part of the economy of
American families. Transportation and communications
systems have not been developed to a point where gen-
eral practitioners should be allowed to decrease in num-
ber. Neither should the necessity of general practitioners
be overlooked in solving the increasing costs of medical
care. How much will medical care cost as the public is
forced to seek its medical care from one specialist after
another instead of from the family doctor?

This continuing decrease of general practitioners
should be recognized as the greatest problem of organ-
ized medicine in this country at the present time. With
its proper solution will come correction of maldistribu-
tion of physicians, decrease of the high cost of medical
care, and higher quality of medical care uniformly over
the whole country.

Unless the medical profession, itself, provides the an-
swer in the not-too-distant future, some governmental
agency will be given control of both medical education
and medical practice in order to permit compulsory
placement of physicians in rural areas. Would it not be
far better to accept the challenge now, and to see that
the profession provides the answer in a democratic man-
ner rather than permit forced regimentation?

E. J.S.

Views Items

At the annual meeting of the American College of
Chest Physicians, held at San Francisco, California, June
27-30, 1946, Dr. Karl H. Pfuetze, Cannon Falls, was
elected governor of the college for the state of Minne-
sota. Dr. Frank I. Terrill, Deer Lodge, was elected
governor of the college for the state of Montana, and
Dr. William L. Meyer, Sanator, was elected governor
for South Dakota.

CORRECTION: The 1947 convention of the South
Dakota State Medical Association will be held May 31
to June 3, inclusive, and the place is Rapid City and not
Redfield, as was previously reported.

Among the fifteen University of Minnesota faculty
members who received commendation for wartime med-
ical research from the Office of Scientific Research and
Development are Drs. Raymond N. Bieter, Owen H.
Wangensteen, and Maurice B. Visscher.

Dr. Leo G. Rigler, Minneapolis, has been appointed
a member of the Committee on Radiology in Industry
and Public Health of the American College of Radi-
ology.

Dr. Cecil J. Watson, Minneapolis, has been elected
president of the American Society for Clinical Investi-
gation.

Dr. Moses Barron, Minneapolis, appeared on the
clinic program of the international diabetes clinic at the
Indiana University Medical Center, Indianapolis, on
September 23, which was sponsored by Eli Lilly and
Company.

Joseph E. Dahl of Minneapolis, now sole owner of
Dahl’s exclusive prescription pharmacies and well known
to the physicians of the area, was elected a fellow of the
American College of Apothecaries at that organization’s
meeting August 26 at Pittsburgh, Pa. The only other
member in Minnesota is Albert Malmo, Duluth. The
society has some 100 members and is confined to ethical
pharmacists.

^beatUi

Dr. A. Howe, 69, former resident of Kalispell, Mon-
tana, died August 24 at Plentywood, where he had lived
the past five years. He began his practice in Kalispell
in 1902.

Dr. S. M. Soulders, 73, died August 29, at Billings,
Montana, where he had practiced for 45 years. In 1917,
Wittenberg college conferred upon him the degree of
master of arts for original contribution in the treatment
of pneumonia. In 1918 he built the Mount Maurice
Hospital and Sanitarium which he operated until his
death.

Dr. J. B. Baasen, 63, died August 11 at Grafton,
North Dakota, where he had practiced for the last four
years. He was formerly of Grand Forks.

John Charnley McKinley, Teacher, Clinician,
Contributor of Knowledge, Administrator
and Benefactor of Mankind

A Personal Appreciation

J. Arthur Myers, M.D.

While instructing in neurology at the University
of Minnesota School of Medicine in 1915, one
of the students showed me some diagrams he had just
prepared of the various nerve tracts. Evidently as he had
struggled along in this subject it had been exceedingly dif-
ficult to visualize the source, course and distribution of
these tracts within the central nervous system. Textbooks
contained numerous illustrations of dissections of certain
parts and cross-sections at various levels of the central
nervous system, but nowhere was there to be found a dia-
grammatic presentation from which the student, or even
the instructor, could clearly visualize and quickly under-
stand the various tracts. This student had seen the need
of such diagrammatic illustrations to elucidate the sub-
ject in his own mind, for obviously he had labored long
and arduously to assemble all the facts available in nu-
merous books and articles concerning each tract. The re-
sult was one of the finest contributions that had been
made to the teaching of neurology. Since that time stu-
dents and instructors everywhere have been able to read-
ily visualize the subject. The student who made this
contribution in 1915 was John Charnley McKinley, who
became a highly respected and outstanding authority on
this subject and, later, of all that pertains to the nervous
system. Before the course in neurology was finished in
1915, Charnley and I became close personal friends, and
this friendship has grown through the passing years.

He was bom in Duluth, Minnesota, on November 8,
1891, and attended the grade schools of that city. After
spending some time in the Duluth Central High School,

he transferred to the Horace Mann High School in
New York City. When his family moved to Minneap-
olis he completed the course at the West High School.
He then entered the University of Minnesota and re-
ceived the Bachelor of Science degree in 1915. Minneso-
ta’s famous anatomist, C. M. Jackson, observed the un-
usual studiousness and ability of McKinley and offered
him a student assistantship while he also studied in the
Graduate School. In 1917 he submitted an excellent
thesis entitled, “Myology of the Newborn Infant,” and
was granted the degree of Master of Arts. During the
school year 1917-1918 he was Instructor in Pathology un-
der the direction of H. E. Robertson and E. T. Bell.

Dr. Bell says: “Dr. J. C. McKinley had a year of
training in Pathology before he began to specialize in
Neurology. It was during this period that I became well
acquainted with him. Rather early in his career he de-
veloped a keen interest in Neurology and he has pursued
this interest with great enthusiasm ever since. This early
work was concerned with Neuropathology, and he was a
pioneer in this field at Minnesota.

“One of Dr. McKinley’s outstanding attributes is his
intellectual and scientific honesty. He never pushed his
conclusions farther than his observations permitted, and
he was ever careful that his fundamental data were cor-
rect.

“Dr. Me Kinley’s enforced retirement is a great loss to
the science of Neurology and Neuropsychiatry, and his
genial personality will be sadly missed by his many
friends and colleagues.”

351

352

The Journal-Lancet

Throughout the years J. C. McKinley’s main interest
was in the nervous system. He favorably impressed A. S.
Hamilton, Chief of the Division of Nervous and Mental
Diseases, who recommended appointment to a teaching
fellowship. This began in 1918 and permitted the com-
pletion of the medical course with the degree of Doctor
of Medicine in 1919. During the summer of that year he
did graduate work in psychiatry at the New York City
Psychiatric Institute. On completion of the fellowship
with Dr. Hamilton in 1921, Dr. McKinley received the
degree of Doctor of Philosophy in Nervous and Mental
Diseases. His thesis, “The Intraneural Plexus and Fas-
ciculi and Fibers in the Sciatic Nerve”, was published in
Archives of Neurology and Psychiatry. Throughout the
period of graduate work in nervous and mental diseases
Dr. Hamilton was fascinated by Dr. McKinley’s teaching
ability, investigative mind, accomplishments in research,
and his vision on needed future developments in the
entire field of nervous and mental diseases. Therefore, he
recommended him for an assistant professorship in neuro-
pathology. After holding this position until 1925 he was
advanced to an associate professorship. The year 1928-
1929 was spent on a fellowship of the John Simon
Guggenheim Foundation, when he conducted studies at
the Universities of Breslau and Munich, Germany. On
returning to the United States in 1929, he was advanced
to a full professorship in neuropsychiatry.

When Dr. Hilding Berglund resigned the headship of
the Department of Medicine in 1932 Dr. McKinley was
appointed Acting Head. Two years later he was pro-
moted to the headship of the Department of Medicine.
He retained and procured the best possible physicians for
teaching, care of patients, and research. Neuropsychiatry
was still one of the divisions of this department for which
he had selected an excellent staff with a splendid teaching
and research program in effect.

Dr. McKinley devoted a large amount of time and
thought to the proper construction of a psychopathic unit
at the University Hospital. In fact, he and Dr. Hamilton
had frequently discussed the importance of such a unit
to the school. For years Dr. McKinley had made obser-
vations on such units in this country and abroad and had
assembled the best designs from many institutions. He
also had numerous excellent original ideas and envisioned
the best unit that could be produced. On numerous
occasions he appeared before the state legislature present-
ing various reasons why funds should be appropriated
for the construction of a psychopathic unit. He was
rewarded for all effort when an adequate sum was appro-
priated and he was ready with the most detailed plans
for construction. When the unit was completed in 1937
nothing had been omitted that would insure the safety of
his mentally ill patients, as well as those who cared for
them. Although this new unit accommodates only thirty-
seven patients, it is adequate, ample and ideal in every
respect.

Dr. McKinley had long desired to limit his activities
to neuropsychiatry, and in 1943 such a department was
established through his efforts. He recommeneded that
Dr. C. J. Watson succeed him as Head of the Depart-

Dr. J. C. McKinley

ment of Medicine. Concerning him, Dr. Watson says:
“It is a genuine pleasure and privilege to participate in an
expression of appreciation of Dr. J. Chamley McKinley.
His enforced retirement from medical teaching and re-
search, and from any active participation in the daily
affairs of the Medical School has removed a strong
prop which many of us, and more particularly I, had
leaned heavily upon for a number of years. It is one of
Dr. McKinley’s many fine traits that he is a sympathetic
listener, always willing to turn over in his mind the prob-
lem which a friend brings to him, and after careful con-
sideration to give helpful and kindly advice. I can well
remember how often in the earlier days of my medical
research, I would turn to Dr. McKinley for advice about
methods and apparatus and even about fundamental
questions to the project at hand even though he at that
time was interested almost entirely in neuropathology
and my interests related to diseases of the blood and
spleen. It was easy to turn to him because he was so will-
ing to be helpful. I have often felt guilty in later years
about the amount of his time that I abstracted in those
days.

“For more than ten years, Dr. McKinley was the
Chairman of the Department of Medicine. As Director
of the Division of Internal Medicine during a good deal
of this period, I had the utmost satisfaction and help
from his counsel. His contribution to a knotty adminis-
trative problem was characteristically clear and incisive,
yet quiet and simple. The privilege of having served

November, 1946

353

under him is one that I shall never minimize.”

When Dr. McKinley became head of the newly
created Department of Neuropsychiatry in 1943, his
entire personnel was carefully chosen and the various
phases of neuropsychiatry were well represented by ex-
perts. The staff has worked most harmoniously in devel-
oping one of the best teaching units to be found any-
where, in arranging for and applying every worth-while
diagnostic and therapeutic procedure and in conducting
research of the highest quality.

Dr. McKinley has always taken tremendous pride in
his students, not only while they were in school, but after
graduation. There was nothing he would not do to help
the individual or the entire class. He devoted a great
deal of time to the preparation and revision of outlines
of courses for students, such as Syllabus and Clinical
Guide, and Outline of Neuropsychiatry. These outlines
were so effffective in teaching that other departments
adopted similar methods.

The numerous and notable contributions Dr.
McKinley made to the literature were headed by a paper
(with E. M. Hammes) on Lethargic Encephalitis, which
was published in 1920. Following this, he contributed

imany articles of scientific and practical value. A few
years ago, Paul B. Hoeber, medical book publisher, chose
Dr. McKinley from among the American workers in
neuropsychiatry to prepare a handbook on neurology and
psychiatry. This was a signal honor. Inasmuch as there
is no such publication in the English language, and of
necessity it would be of considerable magnitude — at
least three large volumes — Dr. McKinley carefully
weighed the project before finally contracting to produce
the manuscript. He proceeded to invite more than twenty
experts in various phases of the subject to contribute
chapters and sections. After the work was well under
way it was interrupted by situations incident to World
War II. However, it is now being resumed and is to
be carried to completion by Doctors Donald Hastings
and A. B. Baker.

For many years Dr. McKinley has been a member of
the editorial board of the Journal-Lancet. In this capacity
he has read and edited all manuscripts submitted for
publication in neuropsychiatry. Moreover, he has edited
special issues devoted entirely to subjects in his field.
It is most fitting that his successor, Dr. Donald Has-
tings, as head of the Department of Neuropsychiaty,
has edited this (November 1946) issue of the Journal-
Lancet, which is dedicated to Dr. McKinley.

Having long been convinced that most disasters in
politics, crime and the like are due to mental disorders
which should be detected before catastrophies occur, Dr.
McKinley aided in legislation concerning psychiatric
problems and was influential in the enactment of the
Minnesota Psychopathic Personality Law. No device was
available for quickly screening such personalities from
any group of individuals. However, in collaboration
with Dr. S. R. Hathaway he developed the Minnesota
Multiphasic Personality Inventory. This is a psycho-
metric device for the more objective evaluation of per-

sonality especially in psychiatric terms. It consists of 550
items that have been found to have discriminatory value
(ex. “I have very few headaches.”) which are given to
the patient for his response as “True” or “False.” To
derive meaning from these responses it was necessary
to obtain such records from hundreds of normal people
and carefully diagnosed patients of all types. Statistical
treatment of the data yielded a number of scales that can
be interpreted as an aid in psychiatric diagnosis and gen-
eral evaluation of the severity of abnormal type personal-
ity reactions.

Dr. McKinley had the rare vision to foresee the value
of such a device and the still rarer strength of purpose to
carry through the years of developmental research before
it was possible to assess the ultimate outcome. He con-
tributed, among other factors, the absolutely essential
staff organization, the psychiatric sophistication, and the
complicated administrational detail behind the project.
The magnitude of these contributions can only be grasped
if one goes back to the time of initiation of the project
and recognizes the reluctance of the scientific world to
accept such an approach.

Through Dr. McKinley’s steadfast backing, the pro-
ject was completed and the present day attitudes are far
different. The MMPI is widely used and accepted.
First published in 1942 by the University Press, it
quickly swamped the local facilities for manufacture and
was released to The Psychological Corporation, New
York, for manufacture and distribution. It is used
routinely by hundreds of private clinics and individual
doctors; it is a part of the personnel procedure in some
of our largest corporations; it was used by individual
medical and psychological personnel in all theatres of
war; Adjutant General Ulio wrote to express personal
appreciation of the contribution made to the war effort;
it is used today in all veterans’ administration medical
clinics and is a part of the required curriculum for train-
ing clinical psychologists under the auspices of the Vet-
erans Administration.

Dr. Hathaway, who has long worked with Dr. McKin-
ley on this and other projects, says: “It is trite to say
that an important measure of the greatness of a man is
the breadth of his interests and abilities. Actual estima-
tion of relative variety in the subject matter of publica-
tions of eminent men has established the truth of the
common saying. Among Dr. McKinley’s professional
qualities, the varied directions of his competance is an
outstanding evidence of his eminence. From his earlier
contribution to our anatomical knowledge of the sciatic
nerve through his work on muscle tonus and poliomye-
litis to the psychological techniques of personality evalua-
tion is a range few of us can competently attain.

“His teaching and publications are an inspiration
toward the higest levels of scientific integrity. His efforts
have always been in the broadest sense directed toward
socially acceptable ends. His methods and recognition
of the contributions of others are marked by honesty
and the fair recognition of the mutual contribution of
his colleagues and students. Few men with administrative
responsibility requiring many arbitrary decisions have as

354

far as he merited the feeling that decisions and policies
derived from honest and impersonal motives.

“When evaluating a man’s contribution, we tend to
ask ourselves what one thing he did that most clearly
established him as deserving a high place in his profes-
sion. Aside from the local personal and professional
position he achieved, I think we may select his indispens-
able contributions to development of the Minnesota
Multiphasic Personality Inventory as his most outstand-
ing work. The thousands of clinical workers routinely
using the MMPI and the already extensive literature on
this device are establishing an enduring monument to
his memory.

“Finally, I wish that I might have the gift to commit
to written words the more personal debt I feel for his
friendship and guidance. The impact of these is not
adequately expressed by professional eminence. Warm
friendship and wise guidance are too restricted and in-
dividual. The debt must be paid in lives modified and
consecrated toward ideals derived from the man’s having
lived. We who continue yet a while can never more
effectively establish the worth of these personal contri-
butions than when we too are judged and through our
lives humbly reflect our recompense to Dr. McKinley
who influenced us.”

Dr. McKinley is such an excellent student of polio-
myelitis in all of its aspects, including the pathology,
that he has been in great demand as a consultant when
the diagnosis or treatment of this disease is in question.
He always has at his tongue’s tip the latest figures con-
cerning the efficacy of the various therapeutic procedures
reported from all parts of the world. The fundamental
knowledge concerning poliomyelitis, particularly its path-
ology, is so well established and Dr. McKinley has so
mastered the subject that he is irked when anyone with-
out true knowledge of the fundamentals of the disease
advances so-called new concepts pertaining to etiology,
location of lesions, diagnosis, treatment and prognosis.

Dr. A. B. Baker, who worked with him on many cases
of poliomyelitis and other diseases of the central nervous
system, says: “When one has worked closely with Dr.
J. C. McKinley for many years, it is difficult to describe
in words the many finer qualities which he possessed.
There is a tendency to emphasize only certain outstand-
ing characteristics and to overlook or minimize many
other excellent ones which one accepts as natural or ex-
pected when actually they are unusual and admirable.
To many, Dr. McKinley is best known as the courageous
champion of his own convictions. It must be emphasized
that every principle advocated and defended by him was
first subjected to much careful thought and scrutiny. His
judgment was not at fault in very many instances. As a
teacher he was unparalleled; his entire academic program
was based upon the firm foundation of good pedagogy.
Research played an important role in his philosophy and
he was always willing to help, to guide, and to support
the investigative efforts of his staff. He made a point of
protecting his staff from the many little nuisances and
duties which would interfere with their work by taking

The Jouunal-Lancet

such duties upon himself at the sacrifice of his own time
and his own pleasures.

“However, to me, Dr. McKinley’s most outstanding
quality was his total lack of personal selfishness. He was
always willing and anxious to help and guide the aca-
demic and scientific development of his staff and col-
leagues and took great pride in their achievements. In
fact, one of the greatest satisfaction one could obtain
was the privilege and pleasure of being able to discuss
problems with him and become infected with his enthu-
siasm and encouragement. Certainly those who worked
with and under Dr. McKinley will, for a long time, feel
his absence from the academic field and will miss greatly
his guidance, advice and physical presence.”

Dr. McKinley’s attitude toward sound and funda-
mental principles in all medical work is well expressed by
Dr. Maurice Visscher: “Dr. J. C. McKinley is one of a
small group of scientifically trained physicians who were
responsible over the past twenty years for establishing in
the University of Minnesota Medical School a center
of sound, creative work in medicine. He could always
be counted upon to stand up for the highest standards,
whether it might be in medical practice, teaching or
research. He has been intolerant of pretense, sham, and
slovenly work, but has never been too busy to give his
time freely to help colleagues in need of assistance or
advice. His incapacitating illness has deprived his insti-
tution and his friends of one of their firmest pillars of
strength.”

Dr. B. C. Schiele, who has been intimately associated
with Dr. McKinley for many years, says: “I think of Dr.
McKinley with deep personal affection. Honest, sincere,
and fair, he has always been sensitive to the problems of
those about him. As a teacher he is able, sound, and
inspiring. A man of high scientific integrity, he believes
strongly in objective methods, valid observation and
honest reporting. He has fought tenaciously for those
things in which he believes. His untimely illness and
incapacitation have caused an irreplaceable loss to his
field of work, to the University and to his friends and
colleagues.”

Dr. McKinley enjoys a fine reputation in neuropsy-
chiatry. For many years he has been in demand as a
consultant among physicians over a wide area. Large
numbers of persons in every walk of life have requested
his advice and assistance. He is exceedingly popular
among the faculty members of the entire University of
Minnesota and has helped many to solve difficulties that
have arisen in their own families.

He is an excellent diagnostician outside his own special
field. A number of years ago, while conducting experi-
mental work on poliomyelitis some of his laboratory
monkeys became tuberculous. A technician who assisted
him was intimately exposed to one of these animals dur-
ing the course of an experiment. Consequently, she de-
veloped mild but suspicious symptoms, and with uncanny
accuracy he outlined a small lesion which other phases of
the examination proved to be tuberculous. Following
this experience he proceeded to eradicate tuberculosis
from the animal colony.

November, 1946

355

He is not given to flattery; therefore, words of praise
have a significant meaning, while criticism is always con-
structive. Never has he failed to manifest the courage of
his convictions. He is trustworthy in every sense of the
word. These and numerous other fine qualities inspire
and warrant confidence. Thus, Dr. McKinley has been
called upon to serve on the most important committees
of the Medical School and the University as a whole. For
example, he was chosen as a member of the all-faculty
committees for the selection of the last two presidents of
the University.

Dr. H. S. Diehl, Dean of Medical Sciences, says:
“Educational institutions are made by men and in the
case of the University of Minnesota Medical School few
men have made as great a contribution to its character
and development as Charnley McKinley. His first fac-
ulty appointment was as a graduate student and instruc-
tor in antomy with a special interest in neuro-anatomy.
Then came graduate work in neuropathology and neuro-
psychiatry, followed by a full time faculty appointment
in the Division of Neuropsychiatry.

“After the death of the late Dr. Arthur Hamilton,
Dr. McKinley was appointed Professor and Director of
the Division of Neuropsychiatry. He served in this ca-
pacity until his retirement on account of illness approxi-
mately a year ago. For several years Dr. McKinley acted
also as Administrative Head of the Department of Medi-
cine.

“As a clinical neurologist and neuropathologist, Dr.
McKinley’s eminence has long been recognized. But he
is not one to be content with the present status of our
knowledge in these fields and was constantly active in
research and the training of graduate students. He has
been deeply interested also in undergraduate medical
education, developing an excellent instructional program
in neuropsychiatry for medical students, and serving as
chairman of the committee which several years ago
planned a complete revision of the teaching program of
the junior and senior years.

“In administrative matters also Dr. McKinley’s broad
interest and sound judgment resulted in assignments of
many special responsibilities and in frequent calls for
advice and counsel. His interests touched every aspect
of the Medical School’s activities. His personal service
and influence have made the University of Minnesota
Medical School a better institution for all time.’’

The members of the Minnesota State Medical Asso-
ciation have high regard for Dr. McKinley as evidenced
by his appointment as Secretary-Treasurer of the State
Board of Examiners in the Basic Sciences in 1931. He
discharged the duties of this position admirably until his
retirement. In 1943 he was appointed Chairman of the
State Association’s Committee on Nervous and Mental
Diseases. This committee made a careful study of the
various problems throughout the state and has already
offered valuable suggestions for their solution.

Memberships are held by Dr. McKinley in numerous
organizations. Among them are the County, State and
American Medical associations, as well as other state
organizations, including the Society of Neurology and

Psychiatry, Academy of Medicine and the Pathological
Society, of which he was president in 1936-37. He also
belongs to many regional and national special organiza-
tions, such as the Central Clinical Research Club, Central
Society for Clinical Research, Central Neuropsychiatric
Association, of which he was president in 1938-1939,
Society of Experimental Biology and Medicine, fellow of
the American Association for the Advancement of Sci-
ence and American Neurological Association. In 1941
he became a member of the Board of Directors of the
American Board of Psychiatry and Neurology. He was
most conscientious with regard to adequate examination
and all other qualifications of applicants before recom-
mending certification to the practice of these specialties.
He was greatly appreciated by the other members of this
Board because he always was present wherever the exam-
inations and meetings were held, and contributed greatly
to the success of the work.

He was elected to membership in the medical scholas-
tic fraternity, Alpha Omega Alpha and his scientific
attainment was such as to admit him to Sigma Xi. For
many years his biographical sketch has appeared in
American Men of Science and Who’s Who in America.

For more than twenty years Dr. McKinley and I have
officed just across the corridor from another in Millard
Hall. At midforenoon we usually went across the street
for coffee. This afforded us an opportunity to chat about
subjects of mutual interest such as teaching, writing, the
control of diseases and conditions in our respective
fields on a national or worldwide basis. We also dis-
cussed vacations and a number of subjects only partially
related to our regular work. One morning in the spring
of 1926, Dr. McKinley came to my office and said he
had learned of some available isolated, heavily wooded
lake shore property in the vicinity of Milltown, Wiscon-
sin. During childhood he had been exceedingly fond of
the out-of-doors and had devoted much time to the woods
and lakes over a wide area in the vicinity of Duluth and
Superior. We went to Milltown and made careful obser-
vations of this particular site and the surrounding coun-
try. It strongly appealed to Dr. McKinley because of
its resemblance to the areas farther north where he had
spent so much time as a child. The land was purchased
and Dr. McKinley located a young contractor who con-
structed cottages for us the following winter. From that
time we regularly spent vacations and summer week ends
together. A little later Dr. C. A. McKinley located ad-
jacent to us. All being members of the staff of the De-
partment of Medicine, we frequently discussed the var-
ious phases of this field. Dr. J. C. McKinley always
had on hand complete first aid equipment and, therefore,
was our group physician. On numerous occasions he
treated wounds of the children and other illnesses of
various members of the colony.

He had a wide variety of interests and succeeded in
everything he attempted. From the Wisconsin Depart-
ment of Forestry he procured hundreds of white pine
seedlings which he carefully planted to establish a pine
forest on his acreage. He excelled in gardening by grow-
ing the finest varieties of vegetables and small fruits. He

356

The Journal-Lancet

knew the trees, the flowers, the birds, the reptiles and
other animals of the woods and lakes. He still holds the
twenty year record for having caught the largest fish of
any member of our group. He took much delight in
swimming and boating. He was a crack marksman with
the rifle and pistol, of which he owned several. He be-
came the friend of the farmers of the community and the
Chippewa Indians on a nearby settlement. The merchants
and other citizens of the villages of Luck and Milltown
soon became his close friends. He took pride in arrang-
ing for an inter-cottage telephone system, a pumping
device for storage water tanks, and numerous other con-
veniences for this limited community. He surrounded
his garden with an electric wire to protect it from the
deer and smaller animals of the forest. These varied
activities were only a part of his recreational interests.

The Sioux Falls, South Dakota, Medical Society,
whose membership includes a considerable number of our
former students, invited Dr. McKinley and me to present
papers in our respective fields on May 8, 1945. We ac-
cepted and made reservations to leave on the same train.
A little before departure time, however, Dr. McKinley
cancelled the trip because of a rather sudden rise of blood
pressure. For some years hypertension had caused him
considerable disturbance. He feared disability from

cerebral hemorrhage much more than death. He had
treated large numbers of such disabled persons and
among them his predecessor, Dr. A. S. Hamilton. Only
a few days after cancelling the Sioux Falls engagement,
on May 11, while taking dinner at the home of a friend
this most feared accident occurred.

The event came as a severe shock to Dr. McKinley’s
host of friends. Most of them have not since seen him.
They have lamented being unable to express their feel-
ings toward him. However, an opportunity came in
October, 1946, when a small self-appointed committee
announced that it would receive letters and have them
bound in a volume, to be presented to Dr. McKinley on
or before his fifty-fifth birthday on November 8. Prompt-
ly these leters began to pour in. What an array of mes-
sages— 200 of them. What expressions of sympathy,
kindliness, affection, friendship, appreciation, esteem, and
everything else to denote a life completely filled with
service to humanity. After all, it is not the number of
years that a man works but what he accomplishes that
counts. Examples are found in the lives of such persons
as Bichat, Chopin, Keats, Laennec, Rhodes, Schiller, and
Thoreau. Like them, Dr. McKinley has kindled fires in
the hearts and minds of men and women that can never
be extinguished.

ARMY NEUROPSYCHIATRIC PROBLEM

During the first six months of 1945 when patients evacuated from overseas reached a
war-time peak, there were actually more psychiatric and neurological patients than medical
patients returned from the Pacific. The significance of this statement is highlighted when one
realizes that the Pacific evacuated a larger percentage of patients for disease than any other
theater. During this same period the number of patients evacuated for neuropsychiatric dis-
orders from the European Theater almost equalled the number evacuated for disease.

The most startling figures are those now first becoming available with the publication
of the medical histories of the field armies. The experiences of the First Army — which ac-
counted for most of the American fighting strength during the first two months after D-Day
in France — have just been published. During these two months, eight divisions can be consid-
ered to have been actively engaged. The records of these divisions reveal that there was one
neuropsychiatric admission out of every two medical admissions. In certain divisions, the ad-
missions for neuropsychiatric causes swamped all other medical admissions. This can be illus-
trated by pointing to one division which had a per annum rate of 944 neuropsychiatric ad-
missions out of 1100 total medical admissions. In non-statistical terms, this means that the
entire strength of the division would have been dissipated within a year as a result of psy-
chiatric casualties if men had not been treated and returned to duty.

In these eight divisions, neuropsychiatric admissions amounted to 200 out of a total of
482 medical admissions per annum or approximately 40 per cent. If these psychiatric casual-
ties had not been effectively treated, one-fifth of the entire divisional strength would have
been lost during the course of a year. — From "Logistics of the Neuropsychiatric Problem of
the Army,” Eli Ginzberg, in Amer. Jour. Psychiatry, May, 1946.

November, 1946

357

War Psychiatry and Its Influence Upon
Postwar Psychiatry and Upon Civilization"

Edward A. Strecker, M.D.f
Philadelphia, Pennsylvania

The law of supply and demand is inexorable. The postwar
patient psychiatric demand has been so great that it cannot be
supplied within the strict confines of psychiatry, and general
medical men want to acquire a certain amount of basic psy-
chiatric understanding, This is particularly true of those physi-
cians who in the war had general medical and surgical duties;
were confronted frequently with situations in which there were
important psychiatric complications and because of lack of psy-
chiatric knowledge were nonplussed and ineffective. The effect
of these several conditions will be to exert frontal psychiatric
and lateral nonpsychiatric pressure upon medical education, in-
creasing the importance of psychiatric teaching and broadening
the scope so that the psychosomatic and other relationships be-
tween psychiatry and medicine and surgery, in all their sub-
divisions, will be adequately taught.

Many generations to come will have to pay for the
huge neuropsychiatric morbidity rate of this war,
if not in blood, certainly in tears and sweat. Surely pre-
vention will have important consideration in the military
psychiatry of the future. Having failed twice within
twenty-five years, and having paid a heavy penalty for
our failures, it is inconceivable that we should again be
remiss in filling the lamps of military psychiatry with
the oil of organization and personnel. No matter how
small the peacetime army may be, there must be main-
tained in the Office of the Surgeon General at least a
skeleton of neuropsychiatric organization, capable of
rapid expansion and in close touch with qualified psy-
chiatric medical personnel, available for service should
the need arise.

Neuropsychiatric induction has not been successful.
Even the small amount of screening it accomplished is
remarkable in view of the dearth of psychiatrists and
the pressure of time permitting at best five minutes to
discover disabilities which rarely have external markings,
as do physical handicaps.

It must be emphasized that many, and indeed the ma-
jority of neuropsychiatric disabilities did not appear as
a result of combat experiences but were detected by the
hundreds of thousands at induction or in training areas
in the continental limits. The bulk of these conditions
was somewhat vaguely psychoneurotic with rather indefi-
nite psychosomatic symptoms or personality disorders
often indicative of grave psychopathic traits, sometimes
suspiciously akin to malingering. It is to be emphasized,
too, that they were merely focused in the regimental
and disciplinary setting of military life. Usually they
existed prior to service and the trail of inadequacy, self-
ish behavior, instability, and lack of social responsiveness

*Compendium of a paper which was delivered at the Post-
graduate Assembly on Nervous and Mental Diseases, and War,
November 2, 1944, and published in Proceedings of the Insti-
tute of Medicine of Chicago, January, 1945.

fProfessor of Psychiatry, University of Pennsylvania School
of Medicine; Consultant for the Secretary of War to the Sur-
geon General of the Army and the Army Air Forces; Con-
sultant to the Surgeon General of the Navy.

is plainly discernible. What is the significance of this
serious situation? Some thoughtful observers believe it
is indicative of softening, a deterioration of our youth.
This is a broad assertion which should not be accepted
without sufficient validation. In any event, here is a
problem which needs thorough discussion and clarifica-
tion. It is not too much to say that unsolved it will
threaten the security of our democratic civilization.

The social portrait of a human being might picture
him surrounded by a series of concentric circles. Those
circles immediate to him might symbolize inalienable
personal rights, a very few personal and sacred rights:
the right to preserve one’s life; the right to bar un-
wanted and unauthorized intruders from one’s home;
the right to worship God as one’s conscience dictates;
the right to think independently though not always to
carry thoughts into action.

Beyond these limited circles of personal liberties there
are more circles. The areas they enclose become pro-
gressively larger and more remote from the central fig-
ure of any individual. It is inevitable that soon these
areas must impinge upon and overlap concentric regions
which encircle other human beings, highly placed or
lowly placed; no one has more than the merest fractional
claim upon such mutually held territory. For instance,
insistence that others must believe and act as we believe
and act and resort to forceful measures to compel agree-
ment is not the exercise of personal liberty.

The existence of true democracy is imperiled not only
by aggressive commission but even more seriously by
omission. There is no need of indicting those who insist
only on the rights and privileges accorded by democracy
and neither understand nor regard the duties and obli-
gations incurred. Only in very small degree are they
responsible for their undemocratic behaviour and the
dangerous situation that is produced. Biological and
constitutional factors cannot be blamed too much. For
one thing, in the group under consideration as revealed
in the huge laboratory of manpower seeking adequate
service by induction and testing men by military service,
generally speaking there was no evidence of intellectual
inferiority but rather there was obvious evidence of emo-
tional and social immaturity. Much more indictable are
the defects in childhood training, particularly in the
parent-child and parent-surrogate-child relationships,
grievous failures in teaching concessions in the matter
of so-called personal rights, a reasonable amount of re-
sponsiveness, and at least a minimum of habituation by
practice of contribution to the social welfare of the fam-
ily and community. Since such lessons can be impressed
only faintly by precept and deeply only by example, one
cannot escape the conclusion that far too many adults
who are responsible for the emotional development of

358

The Journal-Lancet

children are themselves emotionally and socially imma-
ture and consequently basically undemocratic in their
attitudes and behavior.

Human beings threatened with psychic disruption em-
ploy those psychological weapons and devices which ex-
perience has demonstrated as readily available and natur-
ally usable by their particular personalities. In a gen-
eral way, the extrovert who is not deeply sensitive to
the judgment of others, tends unconsciously to employ
simple stratagems which meet his needs, like the con-
version of an emotional conflict into a physically dis-
abling symptom, or perhaps, as in mania, by tremendous
activity, verbal and motor, which serves to distract his
attention from the emotional conflict; the more reflective
introvert is more likely to use his power of thought,
often accomplishing by intricate mechanisms significant
repressions symbolically camouflaged in conscious thought
and behavior.

In neuropsychiatry modern war has not devised totally
new treatment formulae, but there have been skillful
and useful adaptions of known treatments. Narcosis
therapy usually given for a week or ten days or more
has been shortened to one to three days, sometimes fol-
lowed by two weeks of subshock doses of insulin result-
ing in an average weight gain of about twelve pounds.
Grinker advocates narcosynthesis by the use of sodium
pentothal intravenously, and the soldier, in a twilight
zone of consciousness, through suggestion was made to
relive his battle experiences. Perhaps the most impor-
tant development in psychological treatment has been
the application of group psycho-therapy. It treats pa-
tients in groups, and undoubtedly the exchange of ex-
periences and opinions between patients shortens the
time required to bring patients face to face with the
underlying motivations of their reactions. Furthermore,
the group is familiarized with the operations of the
usual mechanisms unconsciously employed as technics
to produce the psychoneurotic escape. Fortunately, the
improvement of group therapy has not been hampered
by crystallizations of theory or practice. Many innova-
tions have been tried. Particularly important is the de-
termination of the relatively greater integrity of recov-
eries on the basis of intellectual understanding and
insight as contrasted to those in which there was an emo-

tional "breaking out” in the shape of emotional expres-
sion and portrayal of the harrowing combat experiences.

For many years we have been talking about the short-
age of psychiatrists. One effect of the war upon civilian
psychiatry will be that we will be compelled to do some-
thing about it. The Army and Navy have given many
medical officers indoctrination courses in psychiatry. It
has been ascertained that at least one-half of these men
want to continue their psychiatric education and prac-
tice psychiatry.

Conclusion

Military psychiatric experiences, particularly as related
to combat, will produce a leavening of therapy. There
will be an eclectic therapeutic viewpoint based on the
necessity of accomplishing restitution in the shortest pos-
sible time without too close adherence to any particular
school of thought or technic. We will witness a three-
pronged attack upon therapeutic technics that are highly
individualistic and very time-consuming. One prong of
attack will come from the great number of patients need-
ing treatment, a second from the shortage of psychia-
trists and the need of their having as wide a patient cov-
erage as possible, the third from the relative success ob-
tained in war from energetic and brief therapies. Psycho-
analysis, the citadel of individualized treatment which
of necessity requires much time, will respond with cer-
tain modifications. It is likely that these modifications
will consist of short-cuts in reaching certain phases of
the analysis, perhaps by utilizing pharmacological tech-
nics or hypnosis or even group therapy.

There will be a tendency to deal therapeutically more
emphatically and intensively with those emotional ex-
periences that are directly related to the symptomatology
of the psychoneuroses. Naturally, the past of the pa-
tient, personally and even phylogenetically, should not
be ruled out of consideration, but its use by the patient
to continue a situation which precludes participation in
everyday realities and activities should be energetically
combated. The inner upheaval due to the dynamic ex-
periences which shaped the neurosis must be experienced
by the patient, and the very fact that they are recent
in the psyche and more readily accessible to the therapy
would give them a larger and firmer leverage with which
to lift the psychoneurosis into more favorable territory.

USE OF THE LIFE CHART IN PSYCHIATRIC CONSULTATION

The scheme of this simple chart in general is as follows: In the left hand column there
are rectangles in which are written the dates; similar spaces in the right hand column are
filled in with the age of the payout in that year; the wide spaces to the left of the center
column are used for medical data and those to the right for social data.

The object of this schematization is to bring out chronological relations: In any long

history taken under the regular headings of chief complaint, present illness, past history,
system review, family history, etc., the significant sequence of events may often be lost sight
of entirely because the social data are written up with no reference ro the medical happenings.
So many details may be brought in to each separate department of the history that one does
not see the important socio-medical concatenations. These are frequently in time sequences
which show on a life chart, so it becomes a useful instrument for either abstracting a history
or taking down histories at the bedside. — Stanley Cobb, M.D., Use of the Life Chart in
Psychiatric Consultation , in Clinical Medicine, September. 1946.

November, 1946

359

What Do We Know of Multiple Sclerosis?

Hans H. Reese, M.D.*

Madison, Wisconsin

Since the first clinical descriptions of disseminated
sclerosis by Cruveilhier and Carswell in 1838 we have
learned much about the clinical and pathological fea-
tures of the disease. However, we do not know as yet
if it is an etiologically uniform disease or if it belongs
in the polyetiological syndromes. As long as the etiology
of even rather frequent disorders is unknown, and I
refer here specifically to multiple sclerosis and to dis-
seminated encephalomyelitis with its characteristic de-
myelination, our theoretical explanations vary and much
depends in the interpretation upon our approach, which
may be as a clinician, a neurohistopathologist, an anato-
mist, or last, but not least, an immunobiologist.

The negative results from experimental investigations
over 108 years include bacteria, viruses, spirochaetae and
spurius agents. During the last century our hypotheti-
cal groping has focused upon myelin destroying enzymes
or lipolytic ferments, upon constitutional dispositional
altered humoral reactions, upon faulty blood clotting
mechanisms, and upon neuroallergic phenomena in the
sense of specific antigen-antibody reactions in the nerv-
ous system.

Multiple sclerosis is characterized pathologically by
(1) demyelinated, glial patches scattered preferably in
the white matter throughout the central nervous system
which are the end-results of an acute stage of tissue
damage with its myelin edema, fat filled microglia ele-
ments, with focal macroglial proliferation (astrocytes)
and with perivascular gitter cell infiltration of the adven-
titial mostly venule spaces. Acute, subacute and chronic
patchy lesions are scattered through the nervous system,
and sometimes quite sharp or faded plaques are seen in
the cerebrum, in the brain stem, in the spinal cord; (2)
by nerve fibers deprived of myelin sheaths (so-called
.naked axis cylinders) with some only partially covered
with tumefied or fragmented myelin and others present-
ing destruction of both the myelin sheaths and the axons
in young and old lesions which are also present in ap-
parently normal appearing tissues of the nervous system,
and (3) by the almost normal ganglion cells even in
areas which are surrounded by active degeneration and
reaction phenomena. Many attempts have been made to
demonstrate various evolutionary stages of the plaques,
of the micro-macroglial proliferations, and of vessel
changes . The present discourse does not attempt to re-
view facts and the discrepancies of the neuropathology
of multiple sclerosis.

The clinical picture of a given case, however, must
be evaluated from the point of view that scattered lesions
vary in their evolution and that only the severely dam-
aged tissue region will mirror clinical symptoms. For this
reason, the age of the demyelinating process, its inten-
sity, and its location are important; furthermore, one
must keep in mind that coalescence of small foci into a
*University of Wisconsin Medical School, Madison.

large plaque occurs frequently, and that the secondary
phenomena of pia-arachnoid involvement intensify and
obscure focal signs.

Many theories as to the etiology of multiple sclerosis
have been presented during 108 years, which in the
hands of well qualified and often critical investigators
have given stimuli to a long scale of therapeutic ap-
proaches, none of which, however, is a specific remedy.
The endless lists of many drugs, non-specific proteins,
vaccines, sera (Laiguel-Lavastine-Karessios or Stransky) ,
lipoid or endocrine substances, and the more heroic meth-
ods of artificial fever, forced spinal drainage, and cer-
vico-dorsal sympathectomy, ganglionectomy, reflect our
searches and failures.

Among the theories of the etiology of multiple sclero-
sis, Putnam’s researches relative to vascular occlusions
and to faulty coagulation factors have great popularity.
Putnam has stated repeatedly that the vascular abnor-
malities are on the venous side and that the different
causes of vascular occlusions may be fibrous plugs or
thrombi. He does not believe that the "sclerotic” changes
are due to local inflammation by toxins, but adheres to
the viewpoint of thromboplastic changes in the clotting
mechanism of the blood in preference to vasospasms.
B. Simon, Putnam, Reese and others have studied blood
coagulation in disseminated sclerosis and other diseases
of the central nervous system. Dow and Berglund have
partly supported Putnam in "the vascular patterns of
lesions in multiple sclerosis,” a theory which is not new,
since it has been discussed already by Rindfleisch and
Ribbert. Of the sixty lesions studied by Dow and Berg-
lund, twenty were without a central vein, twenty were
oriented about a normal appearing vein and only nine
lesions surrounded a vein with a thrombus. However, in
three of these nine lesions the thrombus was outside the
lesion, in three the thrombus was partly within it, and
in only the remaining three was the thrombus confined
to the area. No positive correlation was found between
lesions with a thrombus and the size or shape of the
lesions, except that when a vein was found within an
ellipsoid lesion, its location was almost invariably oriented
along the long axis of the plaque. Dow concludes, "The
view that demyelination in multiple sclerosis is entirely
unrelated to the vascular system does not seem likely in
the light of our findings. To assume that the vascular
changes, especially thrombi, are an essential part in the
pathogenesis of the plaque seems also unlikely, unless
one assumes that venous thrombi disappear completely,
but at the same time one must assume that they existed
long enough to cause permanent demyelination.”

O. Marburg, who has contributed so much to the topic
of multiple sclerosis, believes that the swelling or vari-
cosity of the myelin sheath is secondary to axonal swell-
ing and, since the latter is reversible, the fragmentation
or myelin destruction is a discontinuous process. If,

360

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however, the cause of multiple sclerosis should be due
to lipolytic ferments, then one must assume that the
myelin degeneration is primary. It is very difficult to
demonstrate qualitatively lipolytic ferments or lipases.
Statistics on "lipolytic figures” vary; the high positive
findings may result more from liver dysfunctions, from
altered hepatogenic metabolites and thus prepare the
nervous tissue for pathological changes.

Brinkner, Weil, and others have searched for a de-
myelinating agent in the cerebrospinal fluid, partly be-
cause the focal locations are commonly on the outer and
inner surfaces of the brain, in areas constantly "washed
and contacted” by the ventricular and subarachnoidal
liquor and partly from their experimental researches.
As yet there is no conclusive evidence that a lipolytic
or demyelinating agent is in the spinal fluid and attacks
the tissues by diffusion.

G. B. Hassin is in strict opposition to any vascular
etiology of multiple sclerosis and adheres to his often
expressed viewpoint that it is a specific chronic degenera-
tive disease. He flatly denies that the pathological
changes are produced via the blood stream, and emphat-
ically rejects statements that thrombi are found in un-
complicated cases of multiple sclerosis. Etiological spec-
ulation of a vascular theory have been pushed in the
background recently by Pette and Ferraro, to name two
outstanding investigators, by a new theory of neuro-
allergy, in the sense of antigen-antibody reactions in the
central nervous system. "Pathergie” of Rossle with hyper-
ergic-serous inflammation and specific tissue-allergic in-
flammation in a previously sensitized ectodermal tissue
which is discussed and supported by these investigators
refers to an evaluation and consideration of the timely
reactivity facilities of the total organism and of its spe-
cific tissues to a given irritation. The readiness and capa-
bility of the entire organism to react with its three germ
layer structures against a disease-producing agent de-
termines the severity, prognosis, and cure of a patho-
logical process. The dynamic glia tissue reaction in mul-
tiple sclerosis is directed towards the removal of the dam-
aged myeline sheaths and not towards any causative
agents. Allergic phenomena demonstrate its greatest
reactions at first in the vascular system with serous extra-
vasation due to capillary permeability from venules and
capillaries, with a greater tendency to stasis and to
thrombi formation in the sticky blood vessels, and with
parenchymal demyelination, necrosis or softening.

The clinical findings of remittent and nonremittent-
progressive multiple sclerosis are protean in character,
are geographically and meterorologically variable, and
may involve the entire neuraxis with either prominent
cerebral-cerebellar (cranial nerves) or with spinal (spinal
ganglia and peripheral nerves) signs or with combina-
tion types of both. However, the most common forms
are of gradual onset preceded by vague complaints.
Forty per cent of the cases present as their initial symp-
tom transitory but varying ocular signs, 30 per cent of
the cases show motor and sensory disturbances of varia-
ble intensity in one or both extremities (lowers five times
more involvement than uppers) , and from 3 to 7 per

cent of the cases demonstrate as their initial symptoms,
speech, bladder, single cranial or spinal nerve, and equi-
libratory disturbances, or noteworthy psychopathology.
The mental deviation, most frequently encountered in
65 per cent of the cases, is euphoria with psycho-infan-
tilism and affective lability; true psychotic manifesta-
tions in the form of delirium, hallucinosis and paranoid
states are rather rare initially. Much has been written
about the clinical symptomatology of multiple sclerosis,
therefore a discussion of the various forms, symptoms
and signs of the disease are omitted.

Laboratory findings are of some benefit in the differ-
ential diagnosis. Achlorhydria is commonly a poor prog-
nostic sign for expected remissions since it interferes with
absorption and utilization of essential food nutrients.
The spinal fluid may show changes in the cell count, the
total protein and gold sol curve. It is a common clinical
observation that early multiple sclerosis cases react un-
favorably to spinal punctures with prolonged headaches
and dizziness. The electroencephalogram is in most cases
normal. The pneumoencephalogram varies greatly (Free-
man), and demonstrates in more advanced cases asym-
metrical dilatation of the ventricles, focal enlargement of
convexity sulci and of the frontal or cerebellar lobes,
or sometimes a diffuse enlargement of the subarachnoidal
liquor spaces.

To evaluate any therapy, a large number of patients
with the unquestionable diagnosis of multiple sclerosis
must be treated over long periods. R. M. Brickner col-
lected from the literature experiences and results of many
therapeutic efforts and tabulated the results accordingly.
In my opinion, one must divide the therapeutic test cases
into those with a primary isolated or single neurological
symptom which give the best results, from those with
a recurrent but still single and definite localized symp-
tom which are less responsive to therapy, and in a third
group of nonremittent and progressive multiple signs.
All clinicians agree that the first symptom or sign, due
to a small "fresh” demyelinating plaque regresses at
least subjectively in over 52 per cent of the cases. These
remissions occur spontaneously upon rest, upon change
to a warmer climate and under various medications. In
addition many complaints such as paresthesias, scotoma,
diplopia, fleeting pareses, ataxia, dysuria are prone to
be alleviated by rest and by conservative methods. The
initially severe, persistent complaints and the more dif-
fuse, massive focal symptomatology, pointing at once to
larger demyelinated foci, resist our present therapeutic
armamentarium and progress relentlessly. Exceptions to
these rules are found in many cases, even in those with
a long progressive course with and without remissions.
We are sometimes surprised at their comeback to a use-
ful and productive life.

In all multiple sclerosis cases, whether they be very
early, in intermission, or mildly progressive, we should
try to prevent focal and general infections, to combat
vegetative-endocrine crises (i.e., exposure to cold, chill-
ing, emotional shocks, diet fads and allergy-producing
symptoms) , and to regulate menstruation and pregnancy.
All these factors are aggravating to clinically latent or
active mutliple sclerosis by interfering with and under-

November, 1946

361

mining the homeostatic equilibrium of the organism.
Hereditary, constitutional, and dispositional factors have
been investigated, and the researches on identical twins
(Curtius, Thums, Me Alpine) lead as yet only to oppo-
sitional deductions.

A warning may be issued: Never treat an early mul-
tiple sclerosis case too drastically, either medically or
physio- or hydro-therapeutically. Keep the patient in
bed for four weeks and support him according to the
needs, since our goal is to support the upset homeostasis.

holds true for multiple sclerosis, and the Rh determina-
tion of multiple sclerosis families is not conclusive.

In a previous study we followed Putnam’s suggestion,
that faulty coagulation due to hyperprothrombocytopenia
played a factor in the disease, and therefore evaluated
blood coagulation, clotting and prothrombin (Quick
modified by Stewart-Pohle method) time in remittant
types of multiple sclerosis. Table 2 which has been ex-
tended now to 65 cases demonstrates clearly that prac-
tically all of our cases have a starting hypoprothrombo-

to arrest the disease process, and to protect especially
against recurrences.

We have given attention to blood studies and crystal-
ized our findings in Table 1. The fluctuations in the
total and differential blood studies are insignificant so
that they cannot serve as diagnostic criteria for exacerba-
tions and remissions in uncomplicated multiple sclerosis.
In our series of 241 cases, we studied 65 cases over a
long period in regard to clinical allergic reaction phe-
nomena and analyzed the blood eosinophilia. If we
accept 1.2 per cent as the average eosinophile cell count
in norma! individuals, then there is a definite tendency
to a higher eosinophilia in multiple sclerosis, though
allergic signs in history and clinical examination were
lacking (urticaria, eczema, hay fever, asthma, migraine).
A number of patients (six) have food idiosyncrasies
without positive clinical manifestations, "just a dislike
with mild gastro-intestinal complaints.” Blood grouping
has failed to aid in the prognostication or the suscepti-

bility to multiple sclerosis. The trend of blood groups
in the general population with A slightly larger than O
cytopenia, and that the coagulation time in all cases is
within the accepted normal range of six to twelve min-
utes (Lee-White’s two tube methods) . We used, never-
theless, the anticoagulant Dicoumarin in an effort to
reduce drastically the blood viscosity and to prevent pos-
sible thrombi formation caused by intravasal plugs of
fibrinous, plastocytic or platelet origin. The anticoagu-
lant Dicoumarin was used in 28 cases, varying in their
trial periods from two to four months, to over one
year, and in others over one and a half years.

We have not seen any objective improvement, though
all patients stated that the paresthesias and the muscular
tension sudsided, and that their static and dynamic dys-
functions were less disturbing. The present follow-up
study does not support Putnam’s recent statement, that
anti-coagulant therapy improves objective signs and pre-
vents recurrences. We had discontinued the use of

362

The Journal-Lancet

Dicoumarin in the reviewed patients for more than six
months.

Horton’s histamine treatment has given satisfactory
results in early and remittent cases of multiple sclerosis.
This treatment, following strictly the set-down rules of
Horton, is used at present, but we have advised our
patients additionally to follow an acidifying diet, to
combat fatigue, minor catarrhal infection, and menstrual
discomforts by strict bedrest.

Conclusion

We do not know the etiology of multiple sclerosis.
There is no uniform opinion even from neuropathologi-
cal studies, if the disease process is primarily a degenera-
tive, an infectious or a neuroallergic disease.

There is no specific therapy available, and each case
must be tried on rationally acceptable therapeutic
schemes.

DEFICIT OF PSYCHIATRISTS

According to the Public Health Reports, June 28, 1946, this nation needs approximately
10,000 psychiatrists. There are approximately 3,500 psychiatrists in the country at present.
The fulfillment of this need cannot be attained in the immediate future because of the lack
of teachers, facilities, and candidates. There is a deficit of 3,500 psychiatrists urgently need-
ed for public service; i.e., mental hospitals, clinics, and teaching institutions.

Based on the Bureau of Census preliminary figures for 1943, it is estimated that there
are 155,000 admissions to mental institutions of all types (includes Veterans’ Administration
facilities, but not military establishments) . The great majority of these patients are psy-
chotic. Allowing 3.5 such admissions a week for each resident, there is psychotic and severe
neurotic clinical material enough for training 860 residents per year. (There are 742 resi-
dencies and fellowships in psychiatry listed by the A.M.A., but not all of these meet the
requirements of the American Board of Psychiatry and Neurology, Inc., for training leading
to certification by that Board). This would allow for the graduation of 430 men a year,
based on a two-year training program. At this rate it would require 24 years to make up the
deficit in psychiatrists, allowing for attrition.

November, 1946

363

The Brain Changes Associated with Electrical
Shock Treatment: A Critical Review

Bernard J. Alpers, M.D.*

Philadelphia, Pennsylvania

Since the introduction of electrical shock treatment
as a means of combating psychiatric disorders, great
interest has been manifested in the brain changes which
occur as the result of treatments by this method. Suf-
ficient time has transpired so that it is possible now to
evaluate the results of experimental and clinical reports.
For this reason, it has seemed desirable to review crit-
ically the brain findings in experimentally produced elec-
trical shock, as well as in the human wherever this has
been possible. A survey of recent reports relative to this
problem would lead one to believe that the matter is
settled and that there is nothing further to be said.
There are differences of opinion, however; but even if
the matter is settled, it is well for us to recognize that
this is so, in a problem which was not so long ago, quite
controversial. Moreover, electrical shock treatment is a
severe shaking-up process, the prescription of which
should not be ordered lightly, despite its efficacy in some
forms of psychosis. Recognition of what occurs in the
brain during the course of shock treatment may well
make us pause before adding injury to insult too pro-
miscuously in the course of shock treatment. Though
the method has been used widely in the treatment of
psychiatric disorders, it has not been without its op-
ponents who look with horror on its use and who regard
it as an insult to the nervous system.

With these few words of apology, let us proceed to
a review of the record in the problem of the brain
changes in electrical shock treatment.

Review of Experimental Literature
In order to clarify the approach to a rather involved
problem, I think it may be advisable first to summarize
the reports in experimentally induced electrical shock
and then to survey those pertaining to the human. In
this fashion it may be easier to visualize the changes in
the two categories.

Since the report of brain changes in the cat after ex-
perimentally induced electrical shock was the point of
departure for a number of subsequent controversial
studies, it may be well to begin with a survey of reports
in which changes have been demonstrated in the nervous
system.

ELECTRICAL SHOCK WITH ASSOCIATED
BRAIN CHANGES

In a group of 30 cats given electrical shock, Alpers
and Hughes 1 found evidence of damage to the nervous
system in a high percentage of cases. Of the 30 cats
studied, 14 had subarachnoid hemorrhage in some de-
gree and 9 had hemorrhage within the brain substance
itself. The subarachnoid hemorrhage was not extensive,
except in a few instances. It was usually found scat-

*From the Department of Neurology, Jefferson Medical Col-
lege, Philadelphia, Pennsylvania.

tered over the cerebral hemispheres, but in a few in-
stances it was located around the medulla. The cerebral
hemorrhages were all punctate except in two instances,
in one of which there was a hemorrhagic infarct and in
another a fairly extensive cerebral hemorrhage with hem-
orrhage into the ventricles. The hemorrhages varied
widely in number and size. They were for the most part
scattered, appearing at times in a single area of the
cortex and nowhere else, or occurring as scattered punc-
tate hemorrhages elsewhere in the brain or brain stem.
All parts of the brain were vulnerable — the cerebral
hemispheres, the cerebellum, third ventricle, and hypo-
thalamus.

Similar results were recorded in rabbits by Heilbrunn
and Weil.2 The outstanding feature of their experi-
ments was the presence of localized hemorrhages in the
pia-arachnoid at the base of the brain and over the cere-
bellum and spinal cord. These were combined with small
pericapillary and perivenous hemorrhages, localized chief-
ly in the brain stem and spinal cord. Organization of the
hemorrhages was clearly evident in those animals which
survived for a sufficiently long period of time, thus elim-
inating the possibility that the hemorrhages were agonal.
Similar changes were evident in the areas of hemorrhage
in the meninges, where a mild proliferation of the pial
tissue could be seen. Astrocytic proliferation of mild
degree was seen around the hemorrhages within the brain
stem and spinal cord. The ganglion cells in the imme-
diate vicinity of the hemorrhages were shrunken and
pyknotic.

Studies carried out on dogs by Neuberger, Whitehead,
and Ebaugh 3 indicate that changes occur in the brain
following electrical shock treatments, but in the opinion
of these investigators, they are not serious. The nerve
cells showed widespread damage, sometimes to the point
of ischemic cell changes and severe damage. Satellitosis
and neuronophagia were found occasionally. In some
small areas only pale, ischemic, ghost-like cells remained.
Many cells showed the changes typical of chronic cell
damage, the cells being small, dark and shrunken.
Slight proliferative changes were present in the astro-
cytes and microglia. Myelin sheath damage was found
in a few animals. Vascular dilatation and minute hem-
horrhages were found in the cerebral cortex, in the
meninges, and around the ventricles in some of the brain.

The observed changes, though definite, were not re-
garded as serious. Most of the nerve cells and nuclei
were well preserved; hence the description of widespread
damage of the nerve cells must be regarded to mean
widespread in distribution but not in number. The
changes described in the nerve cells were regarded as
reversible.

A study of the effects of electrical shock treatments in
rats by Heilbrunn 4 reveals the production of hemor-

364

rhages both in the pia-arachnoid and the brain substance.
The meningeal hemorrhages were most numerous and
extensive at the base of the brain and considerably less
frequent over the cerebral hemispheres and the cere-
bellum. The hemorrhages into the brain substance were
found in all the lobes indiscriminately, in the hypo-
thalamus and cerebellum. They had a particular predi-
lection for the pons and medulla. The hemorrhages were
petechial in character. Organization of the hemorrhages
was observed both in the meninges and brain substance.

There appears to be some evidence therefore from ex-
periments in rats, rabbits, cats and dogs, that there is
brain damage with the use of the electrical current for
treatment purposes. I shall not discuss here the validity
of these findings or the objections which have been raised
to them. It seems best simply to record them here and
to leave the controversial aspects for general comment.
Hemorrhages have been found in the meninges, espe-
cially over the brain stem, in the cerebrum, and in the
cerebellum, associated with relatively little glial reaction,
but showing indications of organization.

Opposed to these findings are several studies which
cast considerable doubt on the validity of the observa-
tions recorded.

ELECTRICAL SHOCK WITHOUT BRAIN DAMAGE

In a study of three dogs treated in a fashion similar
to that of humans, Lidbeck 5 found in one animal a
recent perivascular subcortical hemorrhage in the frontal
lobe, three capillaries filled with fibrin thrombi, and
shrunken nerve cells with a reduction in the number of
stainable granules; in two other animals there were occa-
sional areas in which the nerve cells showed a greater
degree of shrinkage than normal. Lidbeck regarded the
findings as insignificant and looked upon the results as
indicating that electrical shock treatment was not dan-
gerous.

In an effort to determine the path of the current in
electrical shock, as well as to study the effects of the
current on the brain tissue, Alexander and Lowenback (!
studied 23 cats, 19 of which received only single elec-
trical shocks. It was pointed out that if changes were
present, they were confined to the path of the current
and were not observed beyond its calculated path. "Sig-
nificant, morphologically recognizable tissue reactions,
vascular or otherwise, were limited to that part of the
brain which was within the path of the current; that is
in our experiments they were limited to the fronto-
cruciate lobes or parts of them. In one animal which
died after multiple shocks, there were, in addition to
the changes within the path, diffuse changes obviously
related to the general circulatory disturbance prior to
the death of the animal. In all other animals, those
parts of the brain which were outside the path of the
current . . . showed no morphological or histological
changes, neither immediately nor at times varying from
a few minutes to nine days after the shocks. Here even
temporary vascular reactions were absent. The parietal
and occipital lobes, the bulk of the temporal lobes and
the brain stem from the thalami backwards showed in
all these animals not only a perfectly normal picture of

The Journal-Lancet

the neural parenchyma, but also a perfectly normal pic-
ture of the vascular pattern.”

"Within the path significant changes could be pro-
duced wtih definite regularity. But the threshold for the
production of changes which were morphologically and
histologically recognizable at times varying from one
half hour to seven days after shock, were rather high.
No such changes were observed in animals which had
received shock from 60 to 450 m.a. for times varying
from 5 to 10 seconds; that is, in animals in which the
current density within the path had not exceeded 0.6
to 4.5 m.a. per square millimeter of the cross-section
of the path through the brain. However, in one animal
which had been given a 300 m.a. shock but which was
killed only 4 minutes after the shock, blanching of the
anterior suprasylvian gyri bilaterally within the path of
the current was noted.”

It seems clear therefore from the work of Alexander
and Lowenback that changes in the brain in electrical
shock, when present, are confined to the path of the
current. What changes were observed under these cir-
cumstances? Of the 19 cats who were given a single
electrical shock 9 were described as showing blanching
of the cortex, 4 had vasoparalytic stasis, and 6 were de-
scribed as having no changes. In the majority of cases
those animals with blanching had no changes in the
nerve cells, axis cylinders, or myelin sheaths. In true
instances of blanching swelling and vacuolation of the
nerve cells were observed and there was swelling and
effilochement of the axis cylinders, with swelling and
decreased intensity of staining of the axis cylinders. In
the majority of cases with blanching there were there-
fore either no changes, or alterations of a minor degree
in the nerve cells, axis cylinders, or myelin sheaths.

Vasoparalytic stasis was found in animals which were
shocked with currents of 2000 m.a. for 5 to 10 seconds
with a maximum current density of 20 m.a. per square
millimeter of the cross section through the path of the
current. It developed therefore in animals shocked by
higher currents. By vasomotor paralysis is meant con-
gestion and extreme dilatation of the capillaries, arteries
and veins, with or without, but usually with, perivenous
hemorrhages.

The threshold for changes in the nerve cells, axis cyl-
inders and myelin sheaths was found to be higher than
that for vascular reactions. No changes in these struc-
tures were found in animals given single shocks of from
60 to 1500 m.a. of 3 to 10 seconds’ duration and sur-
vived from 4 minutes to 7 days. No significant changes
were found in an animal which received six shocks of
1500 m.a., each of which lasted two-fifths of a second.

Significant changes could be produced with single
shocks of higher amperage. As in the case of the vas-
cular reactions, the observed changes were limited to the
path of the current. Reversible cell changes such as
swelling and vacuolation appeared in animals which had
received single shocks of 1800 m.a. for two to four
seconds. After single shocks of 2000 m.a. for five sec-
onds and more, irreversible types of nerve cell changes,
predominantly severe degrees of pyknosis with bizarre
cell deformities were found in cortical areas which

November, 1946

365

showed vasoparalytic stasis and where current density
was great. In the marginal areas where current density
was less the nerve cell changes were reversible.

Axis cylinder threshold changes were found at the
1800 m.a. level. These too were reversible in type, con-
sisting of swelling and unraveling of the fibrillae and in
a few instances fragmentation. Animals shocked with
2000 m.a. showed irreversible changes in the axis cylin-
ders, consisting of bizarre formations, irregular swelling
and shrinkage, and fragmentation.

Myelin sheath changes followed similar rules.

A further study of 13 cats by Winkelman and Moore'
reveals no changes in the meninges and no evidence of
subarachnoid or cortical hemorrhages. Changes were
found in the nerve cells of the cerebral cortex in layers
II and III, in the frontal and parietal cortex. These
consisted of moderate pyknosis of the ganglion cells with
hyperchromia of the smaller nerve cells. The changes
were not different from those of the control animals.
No damage was found in the basal ganglia, hypothala-
mus or ammon’s horn. Pyknosis of the perkinje cells
was found at the summit of the cerebellar folia. The
spinal cord was normal. Winkelman and Moore con-
clude that permanent changes do not occur in electrical
shock, but that intracellular and biochemical changes
take place because of passage of the current and the
resultant convulsion.

A study of adult guinea pigs by Windle, Krief, and
Arieff8 reveals no visible hemorrhages of neurocytological
changes after single shocks of alternating current of 45
volts and 225 to 240 m.a. for (4 to % seconds or of
100 volts and 650 to 725 m.a. for 6 to 12 seconds.

A study of the brain changes in the monkey (macacus
rhesus) was made by Barrera, Lewis, Pacella and Kali-
nowsky.9 The conditions of treatment were made to sim-
ulate as closely as possible those in the human. Seizures
were induced three times per week with voltages varying
from 70 to 135 with current times of .10 to .15 seconds.
Neuropathological findings were surprisingly meagre.
There were no hemorrhages, either petechial or gross.
The blood vessels were normal. There were no changes
in the myelin sheaths, axis cylinders, neuroglia or mi-
croglia. "The nerve cell changes were spotty in distribu-
tion and not localized to any particular portion of the
brain. In the areas involved some of the nerve cells ap-
peared shrunken with pyknosis of the nucleus, paling
of the cytoplasm, and disappearance of the Nissl sub-
stance. Some of the cells were only shadow cells . . .
Changes of this type occurred in small areas and the
nerve cells immediately surrounding these areas were
usually entirely normal . . . The incidence of such
"pathological” changes bore no direct quantitative rela-
tion to any of the characteristics of the series of seizures
administered, i.e., frequency, number of seizures, voltage
or current time passage, type of resulting seizures.”
Similar changes were found in the brains of untreated
animals. "The changes could therefore not be related
to the electrically induced seizure and their significance
in the general behavior of the animal seems relatively
insignificant.” Barrera and his collaborators state that
"in the macacus rhesus monkeys subjected to electrically

induced seizures administered at frequency, voltage, and
current times definitely within the range as utilized in
human treatment, there is no evidence, on the basis of
our work, to indicate a relation between electrically in-
duced seizures and histopathological changes.”

Evidence is offered therefore to indicate (I) that elec-
trical shock treatment is not dangerous, (2) that, if
given within safe limits comparable to those used in the
treatment of humans, it is not associated with permanent
brain damage, (3) that the changes which can be de-
tected subsequent to shock treatments are reversible and
functional, that they are confined to the path of the
current, and that changes when seen in nerve cells, axis
cylinders and myeline sheaths are reversible in character.

I shall leave for subsequent discussion the criticism of
these assertions. For the present it seems best to com-
plete the collection of evidence by a survey of the
changes which have been recorded in the human cases
dying in connection with electrical shock treatment.

Review of Human Material

The findings in the few human cases which have come
to necropsy are almost as conflicting as in experimental
animals. Alpers and Hughes10 reported brain changes in
a woman of 45 who had received 62 electrical shock
treatments over a period of 5 54 months, and who died
7 months after the last treatment, of cardiac failure and
bronchopneumonia. The brain in this case revealed pro-
nounced congestion in many portions of the cerebral
cortex, perivascular hemorrhages, and perivascular edema.
The perivascular hemorrhages were fresh in some in-
stances, but in others there was evidence that the hem-
orrhage was old. Hemorrhages were seen in the thala-
mus, medulla, and cerebellum in addition to the cerebral
cortex and white matter. Punctate hemorrhages were
found under the ependyma of the fourth ventricle.

In a second patient, a woman of 79, who had had six
shock treatments and died five months later there was
found generalized arteriosclerosis, arteriosclerotic heart
disease, sclerosis of the cortical arterioles, ischemic and
chronic cell changes of the cortical ganglion cells, and
an occasional perivascular hemorrhage. All the changes
are probably attributable to the vascular disease of the
brain.

Two additional human cases studied at necropsy were
reported by Ebaugh, Barnacle, and Neuberger.11 The
first was a patient of 57 years who received 13 electrical
shock treatments (85 volts and 900 m.a. for 0.15 sec-
onds) and who died 1J4 hours following the last treat-
ment. The heart showed a soft moist discolored area in
the upper part of the anterior wall and the interventricu-
lar septum, and calcified plaques in the left coronary
artery. In the frontal and temporal lobes were several
small areas of devastation, entirely devoid of ganglion
cells and containing some ghost cells. The astrocytes in
these areas were swollen and there was some prolifera-
tion of the microglia with fat granules in their processes.
Diffuse degeneration of the nerve cells in the cortex was
present, consisting chiefly of shrinkage and sclerosis of
the cells. Ischemic cell changes were seen elsewhere in
the cortex. The hippocampal area revealed ischemic cell

366

The Journal-Lancet

change in scattered nerve cells, with swollen astrocytes
and in some places loss of nerve cells. No changes were
seen in the vessels of the cortex.

The second case concerned a patient of 57 who re-
ceived the same dosage as the preceding patient and died
following the third treatment. No changes were observed
in the heart or other organs. The changes were present
throughout the cortex. Areas of ischemic cell change
were seen. The neuroglial reaction was slight and was
particularly noticeable in the polymorphic layer of the
hippocampus. The thalamus contained occasional pale
and poorly defined nerve cells with vacuolated cytoplasm
and somewhat distorted nuclei. The small cells of the
striatum showed occasional satellitosis and changes simi-
lar to those observed in the thalamus. The cell changes
were patchy. The dorsal vagal nucleus in the medulla
revealed occasional pale cells and ghost cells with neur-
onophagia, enlarged glial nuclei, and small glial rosettes.

Ebaugh and his collaborators believe that the nerve
cell changes may be a part of the seizure reaction and
that all the lesions in the brain were brought about by
the electrical shock treatment.

The problem is elaborated further by Gralnick1- who
reported death following electrical shock in a negro of
38 years who developed syphilis in 1939 but was reported
to have no clinical evidence of the disease in 1942.
Death occurred after the second electrical shock treat-
ment, two days after the shock. Necropsy revealed
edema of the lungs and hypoplasia of the circulatory
system.

The brain revealed diffuse congestion of the blood
vessels, thickening of the vessel walls, and endarteritis
involving the smaller blood vessels. Diffuse degeneration
of nerve cells of varying types was seen in the cerebral
cortex, chiefly of the ischemic variety. Scattered areas
of cell loss were found and some disturbance of the
cortical architecture. A considerable degree of neurono-
phagia was found. The oligoglia cells of the white mat-
ter were increased. Glial nodules were found in the me-
dulla and cerebellum. The glial nuclei were considerably
increased in the region of the auditory, vagus, and tri-
geminal nuclei. Vascular changes were pronounced in
the basal ganglia, some of the vessels showing hyaline
degeneration and calcification. Amyloid bodies were
found in the occipital lobes around the posterior horns
of the lateral ventricles. No fresh hemorrhages were
seen, but blood pigment was seen occasionally around the
blood vessels.

The significance of the case reported by Gralnick is
obscured by the possible complication of cerebral vascular
syphilis, for which reason it seems best not to emphasize
it in an evaluation of the brain changes associated with
electrical shock.

Levy 13 reports brain hemorrhages in a patient who
died of heart failure after electrical shock treatment.
"There were a considerable number of dilated capillaries
with hemorrhages which undoubtedly antedated the acute
myocardial failure, as indicated by the pressure of blood
pigment.”

Attention to the role of circulatory failure in death
from electrical shock treatment was directed by Jetter14

who reported death in three cases following shock treat-
ment. His first patient was a man of 61 who died in
12 minutes following his eighth shock treatment. The
heart revealed extensive obliterating coronary arterio-
sclerosis, a recent myocardial infarct, and hypertrophy
and dilatation. In the brain were moderate sclerosis of
the arteries and arterioles, occasional acellular areas in
the cerebral cortex, moderate hyperemia and occasional
petechial hemorrhages in the white matter. The second
case concerned a patient of 70 years who died 12 min-
utes after the sixth treatment. The heart revealed oblit-
erating coronary sclerosis, an old myocardial infarct, and
hypertrophy and dilatation. The kidney was the seat of
arterial and arteriolar nephrosclerosis. The brain revealed
moderate sclerotic changes in the arteries and arterioles,
occasional acellular areas in the cortex, slight rarefaction
of the myelin around the blood vessels, recent small in-
farcts in all the lobes of the brain, with gitter cells, etc.,
and minor hemorrhages in the white matter. The third
case concerned a young subject of 23 who had had one
course of eight treatments and two months later was
given another course with death ensuing about twelve
hours after the eighth shock. Necropsy revealed severe
pulmonary edema, an acutely dilated heart, acute dif-
fuse glomerulonephritis and acute hyperemia of the
brain.

The death in Jetter’s cases was attributed to heart
failure. The petechial hemorrhages found in the white
matter in two cases were regarded as a manifestation of
agonal anoxemia associated with cardiac collapse.

Six deaths following electrical shock treatment have
been recorded in England and Wales (Napier15). The
situation in three cases may be summarized as follows:
( 1 ) hemorrhage into both thyroid lobes following a
single shock treatment in a subject of 46 years. The
brain showed no significant findings; (2) death from
pulmonary tuberculosis in a subject of 52 who had two
shock treatments and died two months later; (3) hem-
orrhagic staining over the right cerebrum in a patient
of 62 who died 30 minutes after the fourth shock treat-
ment.

The occurrence of fat embolism as a possible factor
in death following electrical shock treatment is reported
by Meyer and Teare.16 Their patient, a man of 63,
collapsed following a single treatment and died twelve
hours later. Study of the brain revealed many capillaries
blocked by fat emboli which were present diffusely
throughout the brain and cerebellum, and were more
frequent in the gray matter. No other changes were
found.

A further case is reported by Gralnick.1- It concerns
a man of 61 who died two days following his second
electrical shock treatment. Autopsy examination revealed
a large meningioma lying in the subfrontal region, pe-
techial hemorrhages in the mesencephalon, the pons, cere-
bellum and white matter. Larger hemorrhages were seen
in the pons.

The findings in the few reported cases of death fol-
lowing electrical shock are conflicting, but they give us
at least some concept of the conditions encountered at
necropsy. On the one hand are reported (1) hemor-

November, 1946

367

rhages of small size and varying age scattered through-
out the brain (Alpers and Hughes) ; (2) scattered areas
of cell loss and ischemic cell change (Ebaugh, Barnacle
and Neuberger) ; (3) no brain change of significance
except for minor petechial hemorrhages in the white
matter associated with acute cardiac failure and attrib-
uted to agonal anoxemia (Jetter) ; (4) fat emboli

(Meyer and Teare).

Not only is there no unanimity of opinion concerning
what occurs in the brain but there is not even uniformity
of findings.

Discussion

It is obvious that there is no agreement on the brain
changes encountered in the course of electrical shock
treatment either in animals or in the human. The prob-
lem however is the same in the two groups — the nature
of the findings and their meaning. In animals the cir-
cumstances can be varied according to the plans of the
investigator, whereas in man the circumstances are
usually beyond the control of the physician. It is pre-
cisely the circumstances of the experiments and the
autopsy studies which have aroused criticism and doubt
and it is to these to which I should like to direct atten-
tion for the moment.

In an effort to ascertain whether brain changes occur
in the course of shock treatment, emphasis has been too
heavily placed on the fatal features of whatever damage
has occurred. Clinical experience has long since taught
that electrical shock treatment is safe and in the vast
majority of instances without danger. It has been esti-
mated that it was a cause of death in 0.05 per cent
(Kolb and Vogel) of 7,207 cases and 0.8 in 11,000
cases (Impostate and Almansi) . The problem is obvi-
ously not whether electrical shock is a cause of death,
but whether it is associated with brain changes of any
sort, and if so what these changes may signify. That
this is an important problem can hardly be denied in
view of the shaking up which patients receive during
the course of a treatment which is now in common use
and which depends for its effectiveness on stimulation
of the cerebral cortex. I shall attempt therefore to ap-
proach the evidence with this issue in mind, and shall
make an effort to determine what we can from the data
now available.

Experimental Data

1. The problem of dosage. That the problem of com-
parable dosage is one of great importance, cannot be
denied. If the results obtained in experimental animals
and in humans are to be evaluated properly, the condi-
tions of dosage and density of current must be similar.
Thus far, no such comparable study has been made to
my knowledge. The dosages used have either been in
excess of those used in humans, or the conditions of
the experiment have differed along other lines. It seems
certain now that the original dosages used in the cats
reported by Alpers and Hughes were greater than those
used in humans and the same is probably true also of
the experiments of Weil. One of the major obstacles
to agreement on the brain changes in shock lies in the
fact that it has been claimed that in those instances

in which irreversible brain damage has been found,
that the dosage in animals is considerably greater than
that used in humans. Neymann, in commenting on
Weil’s experiments in rabbits, estimates the fact that
if the electrodes used were equated for use in human
cases, one would have to use electrodes 100 to 211 cm.2
in area. The currents of 130 volts and 300 m.a. were
strong enough to produce electrical convulsions in prac-
tically any human subject weighing 50 Kg. In the ex-
periments of Alpers and Hughes disc electrodes 5 mm.
in diameter were used and currents of 150 to 200 m.a.
were applied to the scalp.

2. The problem of actual brain damage. It is doubt-
ful whether the conditions of experiments in other re-
ported series are comparable tb those found in the
human. In the majority of the experiments of Alexander
and Lowenback (19 out of 26 animals), only single
shocks were used. The same is true of Windle and his
collaborators who reported no changes in the nerve cells
following electrical shock. The conditions therefore do
not simulate the actual circumstances encountered in
treatment in the human and the reported findings are
of value only in relation to single shock studies. They
give valuable information concerning the functional
changes following single shocks, but they do not repro-
duce the conditions produced in man.

On the other hand, there have been several groups
of experiments in which such conditions have been re-
produced. Here, too, the results are open to criticism.
In four of the animals studied by Alexander and Lowen-
back, "vasoparalytic stasis” was found even with a single
shock, the findings consisting of dilatation of capillaries,
arteries, and veins with or without, but usually with,
perivenous hemorrhages. In one animal which received
52 shocks of 1400 m.a. for a total time of 33 seconds,
severe pyknosis of nerve cells was produced in parts
which were limited to the central core of the current.
Of the three dogs reported by Lidbeck with negative
results, dog 1 (16 treatments, 250-300 m.a. 0.2 seconds)
showed a small perivascular subcortical hemorrhage, with
shrunken nerve cells in all the sections; dogs 2 and 3
(16 treatments, 350 m.a., 0.3 seconds) had a greater
number of shrunken cells. In 13 cats Winkelman and
Moore found moderate pyknosis and hyperchromia of
the smaller nerve cells of Laminae II and III and pyk-
nosis of the purkinje cells. Their conclusion is that
permanent morphological changes do not result from
electrical shock, but that intracellular and biochemical
changes take place from passage of the current and
from the resulting convulsion. Similar changes were
found in monkeys by Barrera and his associates, but
the changes in the nerve cells were not regarded as sig-
nificant because of the disclosure of similar findings in
control animals.

The argument which I am laboring is that brain
changes have been disclosed even in those cases in which
the experiments have been regarded as negative. They
have not consisted of perivenous hemorrhages as a rule,
though these too have been found, but they have been
characterized by changes in the nerve cells themselves,
usually without glial reaction. The problem of para-

368

mount significance is whether changes of any sort occur.
The answer to this must be in the affirmative. Whether
the changes are permanent or transitory is open to in-
vestigation. If hemorrhages develop, the possibility of
permanent damage must be conceded. If sclerosis of
the cells develops, the problem of irreversible change
is not so readily settled, since it is difficult to determine
from fixed specimens alone whether irretrievable damage
to a nerve cell has been done.

Possibly the factor of greatest significance is that
changes of some sort do develop in electrical shock
treatment, and it is therefore not a form of treatment
to be regarded lightly or to be used indiscriminately.
From the experimental evidence alone it is not possible
to assert dogmatically that no brain damage is done by
the passage of repeated electrical currents through the
brain. More data is still necessary.

Human Data

Unfortunately, the missing data and the answer are
not to be found in the cases of death in human subjects
following electrical shock. A variety of findings have
been disclosed: perivascular hemorrhages, areas of cell
loss, diffuse ganglion cell disease, sclerosis of ganglion
cells, and subarachnoid hemorrhage. The subjects in
many instances have fallen within an age range in which
the type of ganglion cell disease recorded could be nor-
mal except for one patient reported by Gralnick in a
subject 38 years of age in whom, unfortunately, the
problem of syphilis complicated the histological picture.

This much is certain: that electrical shock as adminis-
tered to the human is not in itself fatal. Nor is the
cause of death to be found in the brain damage. On
this, all are agreed. Death is usually the result of car-
diac or cardiovascular collapse in subjects with coronary
disease, but isolated instances of death with hemorrhage
into the thyroid gland and in uremia have been recorded.

The problem of vital importance is not whether the
procedure is safe, but whether it is in any sense harmful
by the production of changes of any sort within the
nervous system. The answer is not yet available from
human material. All instances of death following elec-
trical shock treatment are extremely important and re-
quire recording until a more complete picture of what
occurs in the human brain can be elucidated.

MECHANISM OF ACTION OF SHOCK

Though the problem of brain damage is still unsettled,
other vital problems concerning the mechanism of action
of electrical shock have been more or less clarified. It
seems clear that only a small percentage of the electrical
current delivered by the ordinary apparatus is conveyed
through the nervous system. Currents such as those in
routine usage — 70-150 volts, 300-1200 m.a.; 0.1 -0.5 sec-
onds— "would probably be exceedingly dangerous and
probably fatal if such currents in their entirety passed
through the cortex or other parts of the central nervous
system. But such considerations become less significant
when it is realized that probably only a small portion
of the current flowing between the electrodes actually
passes through any one portion or even the entire brain.

The Journal-Lancet

. . . Most of the current appears to pass through the
scalp” (Barrera) .

It seems definite also that whatever brain changes
occur, whether they are transitory or permanent, depend-
ing upon the circumstances of the experiment, they
occur only in the path of the current or at its immediate
periphery. This has been demonstrated by Alexander
and Lowenback. They state that their experiments dem-
onstrate that "changes were produced only within the
path of the current, but that these changes were not
always present throughout the entire path.” On the
other hand it is doubtful whether it is possible to state
definitely that the path of the current can be delineated
by the changes which developed between the electrodes.
Brain tissue is not the ideal conductor of electricity, and
from the standpoint of physics it would be possible to
determine the paths of the current only in the case of
a known good conductor surrounded by a poor con-
ductor. It is questionable whether brain tissue fulfills
these requirements. It seems to be more accurate to
speak of diffusion of the current than of concentration.
Since it is possible also that other factors besides the
electrical current are operative in the brain developments
during shock, it is difficult to be certain which changes
are the result of the direct action of the current and
which are due to other factors. A second factor in the
possible production of brain changes is found in the
excessive stimulation of the vagus-vasomotor centers in
the medulla causing in turn generalized circulatory dis-
turbances interfering with the circulation to the brain
tissue. Finally, possible changes in the brain tissue must
be attributed to the effects of the convulsion itself.

Summary

A survey of the brain changes found in experimental
electrical shock and in reported human cases, reveals a
wide diversity of opinion. In the experimental animal,
on the one hand, are reported petechial hemorrhages
which probably represent the results of greater dosage
and density of current than that used in the treatment
of human beings. In contrast to this are reported scat-
tered cell loss and cell changes which have often been
interpreted as being reversible. Even in instances in
which no significant changes are recorded, there has
been observed an occasional petechial hemorrhage which
has been attributed to overdosage. When such hemor-
rhages have been disclosed in the study of human cases
they have been regarded, as a rule, as agonal.

The results in human cases have been less conclusive
than those reported in experimental animals, since, in
almost every instance, some extraneous factor has entered
into the situation and made analysis of the direct effects
of electrical shock difficult to evaluate. Among such
factors are: advanced age which has introduced doubt
whether the recorded cell changes are due to electrical
shock or to unrelated vascular disease; cardiac complica-
tions which introduce the element of anoxia as an ex-
planation of the brain changes; long latencies between
the termination of shock and the death of the patient;
and complicating syphilis of the brain.

Despite these obfuscating factors, the suspicion per-

November, 1946

369

sists that changes of some sort occur as the result of
electrical shock treatment. The probabilities are that
these are functional in nature in the ordinary case and
are unattended by permanent or irreversible brain dam-
age. Clinical correlations would tend to support this
contention, since the confusion, anxiety, memory loss,
and other effects of shock disappear in the course of
time. The possibility of damage is present, however,
under two conditions: (1) in the presence of a large
number of treatments, even in young and healthy sub-
jects; (2) in the presence of existing brain damage.
I have under my care at the present time a young lawyer
who received elsewhere over 50 shock treatments, and
who, after a year, still complains of enough memory loss
to interfere with his work, though his hypomania has
not recurred. It is doubtful, in my opinion, whether he
will ever regain his normal memory capacity. The rare
indicate also the procedure is not entirely benign, and
that damage may ensue sufficient to cause serious
sequelae.

In an effort to determine whether electrical shock was
a safe procedure, emphasis was placed primarily on
whether it caused irreversible brain damage and whether
it could be regarded as a cause of death. Experience has
shown amply that it is not a cause of death by virtue
of brain damage, and that where death occurs it is
usually the result of cardiovascular disease. The prob-
lem, as I have stated elsewhere, however, is not whether
it causes death, but whether it causes damage and, if so,
how frequently. We are not in possession of the facts
which can answer this question, so that, for the present,
electrical shock must be regarded as a form of treatment
to be used judiciously and sparingly, for those conditions
which can definitely profit by its application.

Though the study of human material has not re-
vealed what happens to the brain in electrical shock,
it has thrown some light on the types of cases which
are likely to develop harmful effects. Autopsied cases
suggest that brain damage is likely to occur in conditions
associated with pre-existing brain damage, as in cerebral
arteriosclerosis. It may be advisable therefore to pre-
scribe shock treatment with caution in instances with
known brain damage.

I realize how indefinite have been my conclusions con-
cerning the effects of electrical shock on the structure
instances of convulsive seizures following electrical shock

of the nervous system, but the available facts have
forced this position upon me. If I have been able to
indicate only that more studies are necessary concerning
the problem in question, and that security in the appli-
cation of shock treatment is ill-founded, I shall not
apologize too profusely for leaving you in a state of
ferment.

Bibliography

1. Alpers, B. J., and Hughes, J.: Changes in the Brain
after Electrically Induced Convulsions in Cats. Arch. Neurol.
Si Psychiat. 47:385 (March), 1942.

2. Heilbrunn, G., and Weil, A.: Pathologic Changes in

the Central Nervous System in Experimental Electric Shock.
Arch. Neurol. Si Psychiat., 47:918 (June), 1942.

3. Neuberger, K. T., Whitehead, H. W., Rutledge, E. K.,
and Ebaugh, F. G.: Pathologic Changes in the Brains of Dogs
Given Repeated Electric Shocks. Am. J. Med. Sci., 204:381
(Sept.), 1942.

4. Heilbrunn, G.: Prevention of Hemorrhages in the Brain
in Experimental Electric Shock. Arch. Neurol. & Psychiat.,
50:450 (Oct.), 1943.

5. Lidbeck, W.: Pathologic Changes in the Brain after

Electric Shock. J. Neuropath. Si Exp. Neurol., 3:81 (Jan.),

1944.

6. Alexander, L., and Loewenback, H.: Experimental

Studies on Electro-shock Treatment. J. Neuropath. St Exp.
Neurol., 3:139 (April), 1944.

7. Winkelman, N. W., and Moore, M. T.: Neurohistologic
Changes in Experimental Electric Shock Treatment. J. Neuro-
path. St Exp. Neurol., 3:199 (July), 1944.

8. Windle, W. F., Krief, W J. S., and Arieff, A. J.
(Unpublished) .

9. Barrera, S. E., Lewis, N. D. C., Pacella, B. L., and Kali-

nowsky, L.: Brain Changes Associated with Electrically Induced
Seizures: Studies in Macacus rhesus. Tran. Am. Neurol.

Assn., 68:31, 1942.

10. Alpers, B. J., and Hughes, J.: Brain Changes in Elec-
trically Induced Convulsions in Humans. J. Neuropath. St
Exp. Neurol., 1:175 (July), 1942.

11. Ebaugh, F., Barnacle, C. H., and Neuberger, C. T.:
Fatalities Following Electric Convulsive Therapy. Arch. Neurol.
Si Psychiat., 49:107 (Jan.), 1943.

12. Gralnick, A.: Fatalities Associated with Electric Shock.
Arch. Neurol. Si Psychiat., 51:397 (April), 1944.

13. Levy: Discussion of paper by Heilbrunn and Weil.
Arch. Neurol. Si Psychiat., 47:928 (June), 1942.

14. Jetter, W. W.: Fatal Circulatory Failure Caused by
Electric Shock Therapy. Arch. Neurol. St Psychiat., 51:557
(June), 1944.

15. Napier, F. J.: Death from Electric Convulsive Therapy.
J. Ment. Sc., 90: 875 (Oct.), 1944.

16. Meyer, A., and Teare, D.: Cerebral Fat Embolism after
Electrical Convulsion Therapy. Brit. Med. Jour., 2:42 (July),

1945.

17. Gralnick, A.: Fatality Incident to Electroshock Treat-

ment. J. Nerv. and Ment. Dis., 102:483 (Nov.), 1945.

A DOCTOR’S MISSION

Jean Jacques Rousseau, in Emile, or Education (1762), Book I, says, "Medicine is all
the fashion in these days, and very naturally. It is the amusement of the idle and unem-
ployed, who do not know what to do with their time in taking care of themselves. If by ill-
luck they had happened to be born immortal, they would have been the most miserable of
men; a life they could not lose would be of no value to them. Such men must have doctors
to threaten and flatter them, to give them the only pleasure they can enjoy, the pleasure of
not being dead.” — From Army Medical Library News, July 1946.

370

The Journal-Lancet

A Note on The Development of Speech Patterns

Roy R. Grinker, M.D.*

Chicago, Illinois

Many traits of the human personality are acquired
by the process of identification with important
figures of the developing child’s immediate personal en-
vironment. Mannerisms, gestures, gaits, facial expres-
sions, tastes or dislikes for foods and types of dress are
some of the visible and observable manifestations of the
products of simple unconscious imitation. These and
many other patterns of behavior are modified by contact
with a constantly changing host of relatives, teachers and
other idealized or loved persons. They may continue to
shift even in adult life as in the case of the subordinate
who adopts the gestures and manners of each of his
succession of chiefs.

Less obvious results of identification are more subtle
expressions of the personality that arise from incorpora-
tion of fragments of the behavior of idealized persons
of the childhood environment. These become precipitated
as parts of the individual’s ideals and color his ethics,
morality or tolerance toward himself and others. Ego
identifications are more complicated and less definable,
manifesting themselves by types of reactivity to specific
conflictual situations, by manners of solution of life prob-
lems, by the type of reactivity under stress and by the
character or psychoneurosis in adult life. Less obvious,
more subtly expressed, they are also properties of deeper
personality levels and are more fixed and less modifiable
by fresh identifications.

The pattern of speech is an easily observable external
manifestation of the personality. Man tends to judge
his fellows quickly by the several qualities expressed in
their verbalizations. Grammatical correctness, syntax, vo-
cabulary, inflection, pronunciation, apart from the con-
tent of the speech, are criteria not only of education and
culture, but also of personality. Speech is, therefore, con-
stantly guarded in more formal interpersonal communi-
cation and it is usually modified with progress in cul-
tural development. It is, therefore, surprising to find in
American-borne, well-educated and intelligent persons,
marked residues of foreign sounds, old-world inflections
and even primitive speech patterns. One is tempted to
explain these old incongruous precipitates of speech by
the simplest and most obvious means. Perhaps the sec-
ond or third generation Americans have patterned their
speech after the immigrant parent or grandparent by
whom they have been raised. Perhaps they have been
taught the language of the Fatherland in childhood
simultaneously with English, and therefore retain a par-
tial foreign characteristic in articulation, manifested by
more audible gutturals, harsher consonants or by special
inflections. Such explanations do not completely satisfy,
especially when "d” replaces "th” or when the vocabu-
lary is limited in spite of the fact that every other Ameri-
can cultural pattern is adopted with violent renunciation

*From the Division of Neuropsychiatry of the Michael Reese
Hospital, Chicago, Illinois.

of the "old foreign.” What then holds the young Amer-
ican to some remnant of speech pattern of his parents
whose other foreign cultural patterns he despises, whose
old worldliness causes him shame? Why does he keep
this one clear and obvious stigma of the old?

I shall attempt to outline only one possible explana-
tion among several that are applicable to various types,
by giving a fragment of an analysis which resulted in a
complete metamorphosis of the speech pattern from that
of a low immigrant type to one of an educated American.
The analytic work leading up to the crucial interpreta-
tion and the subsequent analysis still in progress are not
necessary for an understanding of the dynamics of the
abnormal speech. From one case far reaching conclusions
and general explanation cannot be made. Yet it can be
suggested that similar processes are at work in other
individuals who maintain an unmodifiable remnant of
parent speech although all other external behavior has
been adapted to American customs.

Mr. S. is a 36 year old male who has suffered from
a severe obsessional neurosis for about five years. He
has been treated by support, persuasion, scolding and
hospitalization and finally began his analysis after all
other procedures had failed. He had many obsessions
and much ritualistic compulsive thinking but little in
the way of overt ceremonial behavior. Since the onset
of his neurosis he had always had great quantities of
free anxiety which was centered around the idea that
he might go insane. Through devious channels of almost
ludicrous complexity he could develop the possibility of
his impending insanity from very little evidence. If any-
one in his family developed any nervous disorder, the
patient could go insane because insanity was inheritable.
He would call distant relatives on the telephone or write
to them in order to read into their conversations or let-
ters evidences of instability which would mean without
question that he would go insane.

Mr. S. is American born, the only child of Bohemian
parents who spoke their mother tongue and used Eng-
lish poorly. The father, who died after the patient had
developed his neurosis, was an intelligent wastrel who
spent his life in coffee houses drinking and gambling
after failing in every job and business venture he at-
tempted. He was brutal to his family, completely tyran-
nizing his wife and only child with physical and verbal
blows. The patient was permitted no freedom or inde-
pendence and was not even given decent clothes to wear.
The mother was a weak, ineffectual woman who was
fearful of all the world and with her mother believed
in magic and superstition. She maintained only the bare
rudiments of a home. The patient finished grade school
and learned the butchering trade and was always suc-
cessful in his work life and alone supported the family.
After falling in love and marrying the daughter of a
wealthy department store owner, he entered her family’s

November, 1946

371

business at which he made a phenomenal success. On
his father-in-law’s death he managed the store so well
that he surpassed its previous sales records even under
bad conditions.

During the opening phases of his analysis the pa-
tient presented a problem in communications with the
analyst. He spoke in a soporific monotone. "Dese”,
"dats”, and "dose” were used instead of these, that and
those. His vocabulary was meager and filled with slang,
vulgar expressions and obscenities. The analyst’s interpre-
tations were constantly interrupted by the patient’s re-
quest for repetition in simpler terms. He understood few
polysyllabic words and frequently requested definitions
of even simple phrases. It was like talking to a 10 year
old boy instead of to a successful business executive. Yet
the patient was highly intelligent, which made the dis-
crepancy between internal thought and external expres-
sion all the greater and more puzzling. There was no
indication of conscious deception in his ignorance and
no suspicion that he used the technique of non-under-
standing as resistance or hostility to the therapist.

Durng the analysis the patient’s mother developed evi-
dences of metastatic carcinomatosis from the breast
which had been removed a few months prior. Great
quantities of guilt were felt and expressed by the patient
due to close-to-conscious hostility to the mother. It soon
became obvious that the most superficial explanation for
this hostility was the feeling that his mother should not
have stayed with the father and permitted the patient
to be subjected to his childhood mistreatment.

As the mother became weaker, the patient became
more anxious which he rationalized on the possibility of
his impending insanity. If the mother becomes very
sick she might go insane at the end and then surely so
would her son. At that time he had a dream as follows:

"I am in de cemetery standing by a grave, an open
grave. I see dem push a coffin down. I am looking in-
side de coffin and dere is my ma but I don’t feel no
sadness.”

This dream was recounted with great anxiety and
crying. It was terrible, here his mother was dying and
suffering and her son dreamed she was dead. "Really
I love my ma. I want that she should live. What a
bastard I am to dream dis. I really must be nuts.”

The analyst interpreted to the patient that he was
reacting to his dream as if it were a death wish to the
mother but that it had no reference to the now living
and suffering mother. The dream indicated a wish for
the death of the mother inside himself. It was also quite
obvious that he felt guilty and was punishing himself
with the threat of insanity.

The patient then began to associate on how much he
was like his mother. He was fearful and superstitious
and still had the same magical beliefs that she had.
He told of many examples of similarity in their atti-
tudes and emotionality. He then remembered that as a
child his mother used to take him to the cemetery to
visit the family graves. They had to walk along a road
from the end of the streetcar line past the Chicago State
Hospital for the Insane and his mother told him of the
horrible people locked up because they were "mad”.

The analyst pointed out that insanity and death were
linked together and inseparable in his mind. To wish
anyone bad, to wish death was an angry or mad attitude
punishable in kind by going "mad” or insane. This in-
terpretation was received by the patient with a severe
emotional but confirmatory reaction. With tears and
sobbing he stated that he knew all the time that he felt
enraged at his mother for having kept him in such a
horrible existence but now he has the feeling it’s true.

This piece of analytic work clearly demonstrated the
anger toward the mother which could not be expressed
in childhood but was the motive power for an incorpora-
tion or identification of her. This may be called identifi-
cation because of hostility. The aggressions, guilt and
punishment then became intrapsychic processes with
symptoms of depression, guilt and search for rationalized
suffering.

The next day the patient returned in a quiet state and
to the analyst’s surprise began his associations in perfect
English. No longer were the articles mispronounced and
the vocabulary was remarkably expanded. The reader
will recall that no interpretations concerning speech or
vocabulary had been made. The patient asked the ana-
lyst if he noticed anything different in his speech. When
answered in the affirmative he stated that not only had
he been emotional and superstitious like his mother but
he had talked like her. He recalled how she had made
fun of him as a child for the new and long words he
had learned and tried to use.

Gradually, over a period of weeks, the patient’s speech
improved not only in pronunciation and grammar but
the monotony gave way to a normal rhythm of inflection
and a more agreeable pitch. Interpretations, even though
given in complicated English, were understood. Some-
times after using an exceptionally long word or a com-
plicated phrase the patient would stop and admire in
astonishment his sudden newly-found vocabulary.

The mistaken notion is often encountered that iden-
tification is always based on love of an authoritative or
idealized figure who is imitated. Experience in the army
with combat veterans who have developed psychopathic-
like personalities with antisocial and aggressive tenden-
cies proved conclusively the frequency of identifications
based on hostility. In boys, whose internalized checks
and controls were developed late in life outside the home
and were, therefore, weak and easily dislodged by the
permissive and required aggressiveness in combat, the
early roots of the superego were shown to be corrupt and
destructive and based on early hostility to a sadistic
parent.

It is my thesis that speech patterns that are non-
adaptive and represent a lag behind other intellectual
and cultural achievements are identifications formed at
an early age in the oral sadistic phase of development
and are based on hostility to the person with whom the
identification is made. Later modifications of speech
patterns are possible only if the child can overcome his
ambivalence and fuse his love and hate. Where foreign
speech patterns persist as a cultural lag, hostility to the
parental figures has not been adequately solved and rep-
resents an unmodified hostile identification.

372

The Journal-Lancet

Neuritis Ossificans with Osteogenic Sarcoma in
Brachial Plexus Following Trauma: Report of Case

Henry W. Woltman, M.D.*

Alfred W. Adson, M.D.r
Kenneth H. Abbott, M.D.Ji
Rochester, Minnesota

The immediate effects of an injury are often of great-
er legal than medical interest. Delayed effects may
be disconcerting to the attorney, but they often introduce
more interesting aspects to the physician. It is for the
latter reason and because of the extreme rarity of the
condition that the following report of a case is placed in
record.

Report of Case

A housewife and cook, aged twenty-nine years, pre-
sented herself on February 15, 1939, the chief symptoms
of which she complained being pain, weakness and wast-
ing of the left upper extremity. Minor symptoms includ-
ed some deterioration of vision during the previous five
years, and during the past two weeks, an occasional ring-
ing m the ears, like the sound of a bell.

The patient’s family history, past history and marital
history disclosed nothing remarkable.

She attributed the disability in her arm to an accident
she had had two years before. In April, 1937, while she
was making her way along a sidewalk and against a
strong wind, a heavy sign was blown over and fell
against her right lower limb. This, in turn, threw her
against a building, which she struck with her left shoul-
der. She was rendered unconscious for a moment and
then became aware of a bruised shoulder. She noted
that the skin was intact and walked to the office of a
physician, who found no bones broken. Pain in the
shoulder became extremely severe and five or six days
later began to shoot down the outer aspect of the left
arm and forearm. Two months after the injury, she
became aware that the muscles of the posterior aspect of
the shoulder and of the dorsolateral aspect of the fore-
arm had become wasted. She also observed some twitch-
ing of the muscles back of the left arm. One year after
the injury, a sensation of numbness appeared along the
lateral surface of the left arm, forearm, thumb and index
finger. One month before she came, the pain, which had
tormented her daily, left abruptly and coincidentally with
her discovery of an inability to raise the left arm at the
shoulder, to extend the arm at the elbow and to extend
the wrist. Although she said that the paralysis had ap-
peared suddenly, she seemed none too certain of this.

The patient was a well-developed, fairly well-nourished,
co-operative and friendly Italian woman. There was
slight scoliosis and the left shoulder was carried a little

*Section on Neurology, Mayo Clinic, Rochester, Minn.

■(‘Section on Neurologic Surgery, Mayo Clinic, Rochester, Minn.
ifFellow in Neurologic Surgery, Mayo Foundation, Rochester,
Minn.

higher than the right. Both upper and lower extremities
on the left measured from to inch (o.6 to 1.3 cm.)
less in circumference than those on the right. The left
upper extremity perspired more than did the right and it
was also cooler. Except for some myopia, the examination
of the eyes gave negative results. She was recovering
from the tinnitus and from a recent cold.

The principal findings noted on neurologic examina-
tion included complete paralysis and atrophy of the left
deltoid; however, moderate abduction of the left arm
could be accomplished by accessory muscles. The triceps
and brachioradialis were also completely paralyzed and
internal rotation of the left forearm was moderately im-
paired. The triceps reflex on the left side was absent.
Over the outer aspect of the arm was a longitudinally
oriented strip of skin that was moderately insensitive to
touch, markedly insensitive to pain and completely in-
sensitive to temperature (Fig. 1).

Urinalysis, hemoglobin determination, flocculation reac-
tions of the blood for syphilis and roentgenograms of the
skull, cervical segment of the spinal column and left
shoulder were negative. On examination, the cerebrospinal
fluid was entirely normal: the Kolmer and Kline reactions
were negative, the reaction for globulin was negative,
the content of protein was 30 mg. per 100 c.c., there was
one small lymphocyte to the cubic millimeter, and the
colloidal gold reaction was 0000000000. The initial pres-
sure of the spinal fluid was 17 cm. of water with the
patient lying on her side, and response to jugular com-
pression tests was prompt.

A diagnosis of brachial neuritis often is made with
great freedom; yet underlying it must be a cause, the
demonstration of which is often beset with difficulty. A
thorough discussion of the differential diagnosis would
become too long. The first possibility that received
serious consideration was that of neoplasm. Of this, the
usual signal is a focal lesion with progression. We could
not be sure that the disturbance was steadily progressive
and we could find no evidence of a tumor.

Among possible occupational hazards, the patient men-
tioned that for five years she had polished a copper bar
daily and had washed the clothing of a brother who was
working in a lead and zinc refining plant. Blood smears
showed no basophilic stippling and there were no other
symptoms or signs of lead poisoning.

Why continue to think of a tumor when there was
such a good history of an injury? After all, “ascending
neuritis” following injury is not unknown and contracting
scar tissue is commonly invoked to explain extension of

November, 1946

373

Fig. 1. Sensory disturbance as noted April 6, 1940. The arabic numerals designate tactile sensation;
the encircled arabic numerals, appreciation of pain; the roman numerals, appreciation of temperature.
0 signifies normal, — 1 slight impairment, — 4 complete absence.

a disability following injury. It was concluded that the
disturbance was the result of trauma and a diagnosis
was made of posttraumatic neuritis, or plexitis, involving
principally the posterior cord. The arm was supported,
physical therapy instituted and a favorable prognosis was
given.

The patient returned April 6, 1940, and reported that
she had improved, was free from pain and could now
raise the arm to her head. The muscles previously para-
lyzed had remained so.

Nothing further was heard from the patient until May
20, 1946, when she reregistered. She said that the im-
provement that had taken place was lost about 1942 and
that since then she had had a constant, crushing pain in
the left hand and forearm and in the left upper portion
of the thorax. This pain was subject to exacerbations and
remissions. In January, 1945, loss of sensation in the left
upper extremity had become so marked that she had
burned herself severely without any knowledge of it.
In March, 1946, there appeared as well, constant burning
in the right lower extremity and some staggering in
walking. In May, she said, she had vomited some blood.
However, this seems to have been blood-streaked sputum.

She also believed herself to be pregnant and the examina-
tion disclosed this to be true. The fundus of the uterus,
about three times normal size, was incarcerated in the
sacral pelvis but eventually could be liberated.

At this time, the entire left upper extremity was com-
pletely paralyzed, atrophied and anesthetic (Fig. 2).
There was also impairment in appreciation of pain and
temperature on the right side from the third intercostal
space downward and complete loss of appreciation of pain
and temperature of the right leg and foot. Tactile sensa-
tion was retained on the right side. The tendon reflexes
were absent in the left upper extremity but the quadriceps
and triceps surae reflexes were more active on the left
than on the right. Babinski’s sign was slightly positive on
the left and minimal on the right. Appreciation of vibra-
tion and movements of the joints was normal in both
lower extremities.

Urinalysis gave negative results. The concentration of
hemoglobin was 9.3 gm. per 100 c.c. of blood; the ery-
throcytes numbered 3,900,000 and leukocytes 10,000 per
cubic millimeter of blood. Kline, Kahn, Hinton and
Kolmer tests of the blood gave negative results. Roent-
genograms of the thorax were negative and examination

374

The Journal-Lancet

Fig. 2. On May 22, 1946, the above sensory disturbances were noted. The significance of the
numerals is explained in Figure 1.

of the sputum for Mycobacterium tuberculosis gave
negative results. Roentgenograms of the cervical and
thoracic segments of the spinal column disclosed a large
irregular mass of calcification in the soft tissue lateral to
the lower cervical portion of the spinal column and in
the supraclavicular region on the left side (Fig. 3). These
findings suggested myositis ossificans but it occupied the
region of the left brachial plexus. Traversing the left
supraclavicular region from the shoulder obliquely up-
ward toward the neck could be felt a stony-hard, firmly
anchored ridge. We assumed that this represented a
deposit of calcium along the sheath of the brachial plexus
The neurologic findings were those of a complete
lesion of the left brachial plexus and a Brown-Sequard
syndrome caused by a lesion possibly at the first thoracic
segment on the left side. This location of the lesion was
postulated because no sensory disturbance was found in
the right upper extremity, whereas such a disturbance
might be expected if the lesion were situated higher in
the cervical portion of the spinal cord. The complete
functional loss of the left brachial plexus obliterated any
signs on this side that might have assisted in establishing
the level of the lesion.

Fig. 3. Roentgenogram of cervical segment of the spinal column
revealing extensive plaquelike calcification in lesion of brachial
plexus. Right hemilaminectomy C4-C7.

November, 1946

375

Fig. 4. Section from differentiated portion of the tumor, show-
ing relatively normal architecture of bone (hematoxylin and eosin
x50).

Since the patient gave a history of having pain in her
thorax and she had coughed up blood, we thought again
of a tumor, possibly a Pancoast or sulcus tumor, at the
apex of a lung, which commonly invades the brachial
plexus. However, the course of the illness was not rapid
enough for this, roentgenograms of the lungs disclosed
no such tumor and the lesion was calcified. For the second
time, we considered, then discarded, the diagnosis of
neoplasm. We returned to the assumption that injury
had been followed by hemorrhage into the brachial plexus
with subsequent calcification of this hemorrhage.

On May 30, one of us (Adson) performed unilateral
iaminectomy, removing the left laminae of the fifth, sixth
and seventh cervical and first thoracic vertebrae and in
part that of the second thoracic vertebra. This uncovered
a mass which appeared to intrude through the foramen
between the fifth and sixth cervical vertebrae into the
spinal canal, extended over the dura and became adherent
to the cord. The mass was part of a sensory root. It did
not invade the cord but indented it and displaced it
toward the opposite side. There were many adhesions
between the nerve roots and the cord. The sensory root
with its contained mass was excised, thus freeing the cord.
The tissue, on examination, was reported as showing a
reorganizing calcified and fibrotic hemorrhage.

These findings seemed to verify our impression that
the old trauma had caused a hemorrhage that extended
along the plexus, was slowly organized, then calcified and
eventually compressed the plexus, thus accounting for the
prolonged course and subsequent disability.

This explanation seemed plausible; however, it was
unique in our experience. On June 13, the left brachial
plexus was explored. It was found to be calcified and
gave one the impression of a rib. Flakes of bone chipped
off as a specimen about 1 cm. in length and 3 or 4 mm.
in diameter were removed from the fifth cervical nerve.
The center of the nerve appeared to be somewhat softer
than the periphery and now did not give the impression
of a hematoma but of what was called “neuritis ossi-
ficans.” The pathologist reported the specimen to be an
osteogenic sarcoma, grade 1 (Broders’ method) , differ-
entiating into mature bone (Figs. 4, 5, 6 and 7).

On June 28, the patient reported that almost all of
the burning pain had left the right lower extremity and
that the left lower extremity seemed to be considerably
stronger than it had been. The postoperative course was
otherwise uneventful.

On August 12, the patient’s daughter wrote that the
pain in the left upper extremity had returned and that
the left lower extremity was somewhat unsteady. The
pregnancy was progressing in a normal manner.

Comment

The development of a tumor at the site of an injury
has been observed so often that some relationship be-
tween the two is no longer questioned.1 Just what takes
place to initiate the hyperplastic response is not known,
and this case sheds no light on this problem. A rare
feature in this case is the extensive deposition of calcium
in the brachial plexus. Burge and his associates2 stated
that active, injured and dying tissues are electronegative

Fig. 5. Detailed view of an area in Figure 4, depicting two
haversian canals. Mature osteoblasts are seen scattered about in an
osseous matrix (hematoxylin and eosin x200).

376

The Journal-Lancet

to inactive, uninjured and sound tissues, a situation that
may be related to pathologic calcification.

Unusual clinical pictures and metabolic problems arise
also in cases of extensive and massive calcinosis of sub-
cutaneous* and fascial4 structures. Such disorders may
begin in childhood and lead to cutaneous ulceration of
calcareous tubers and extensive immobilization of the
musculature. Periarterial deposition of calcium phos-
phates and carbonates may become so extensive as to
make the taking of the blood pressure impossible; yet the
patient may reach advanced age without distress or
restricted activity.

Israel5 described extensive calcification in the “organs
of movement,” that is, bone, joint capsules and fascia, in
the limbs of patients who have been paralyzed by some
central neurologic lesion. The only case that could be
discovered in the available literature in which extensive
calcification was described in a nerve was one included in
his series. This concerned a twenty-nine-year-old woman
who had myelitis and decubitus ulcer. The left sciatic
nerve, 5 cm. below its origin, was surrounded by an
epineural shell of bone for a distance of 7.5 cm.

In our case, some of the calcification found in the
plexus may have been related to an old hemorrhage, as
biopsy of the tissue taken from the spinal canal sug-
gested, but most of it probably was related to the osteo-
genic sarcoma noted in the tissue removed at the second
operation. Such “parosteal osteoidsarcomas,” as Virchow6
called them, are also rare and have been noted in fascia

Fig. 7. Details of malignant osteoblasts, one in the process of
undergoing division through pathologic mitosis (hematoxylin and
eosin x800).

tv?.'. - *• 'rW.

A. tu? L:

■* if

; te&a© i?

S'k>^r. >'\

- *\ » *

1 dS' *• V *•'*7. <

f. **•*>•• 4. V*- ,

*’> ■**

-•V, ■ >. *?• *■

m m ^1* I M ^ 4 *

m tMf

~ * #

% *

Fig. 6. View of one of the more undifferentiated regions of the
tumor, showing fibroblastic and osteoblastic cells lying in a fibro-
osteoid matrix. Osteogenic sarcoma, grade 1 (hematoxylin and
eosin x!80).

at some distance from bone and in the sheath of the
carotid vessels.7

Summary

The case here reported concerned a thirty-six-year-old
woman in whom, after an injury to the shoulder, there
appeared, first a paralysis of the brachial plexus, and
then a Brown-Sequard syndrome. Laminectomy disclosed
a calcified fibrotic hemorrhage; exploration of the brachial
plexus disclosed an osteogenic sarcoma. The relationship
of the lesion to the trauma and the massive, palpable,
stony plexus, visualized also in the roentgenograms, are
features of unusual interest and rare occurrence.

References

1. Girard, Henry: Sur les osteo-sarcomes d’origine costale.
Sarcome de la dixieme cote droite. Bull, et mem. Soc. d. chirur-
giens de Paris. 36:882 (July 27), 1910.

2. Burge, W. E., Orth, O. S., Neild, H. W., Ash, J., and
Krouse, R.: Mechanism of pathologic calcification, Arch. Path.
20:690 (Nov.), 1935.

3. Fock, Herbert: Ein Fall von Kalkablagerungen unter der
Haut oder sog. “Kalkgicht,” Acta med. Scandinav. 65:169, 1926-
1927.

4. Cohn, Max and Freye: Ungewohnliche Kalkablagerung im
Bindegewebe, Med. Klin. 26 (pt. 2):1400 (Sept. 19), 1930.

5. Israel, Arthur: Ueber neuropathische Verknocherungen in
zentral gelahmten Gliedern. Arch. f. klin. Chir. 118:507, 1921.

6. Hammer: Ueber ein malignes fasciales Riesenzellensarkom
mit Knochenbildung, Beitr. z. klin. Chir. 31:727 (Nov.), 1901.

7. Adams, John : Enchondroma from the anterior part of the
sheath of the carotid vessels (Abst.) , Tr. Path. Soc. London.
1:153, 1846-1848.

November, 1946

377

The Psychiatrist Looks at Family Life

Douglas D. Bond, M.D.* *

Cleveland, Ohio

This title is an open one, because any psychiatrist, in
a way, does nothing but look at family life. Many
of you may have the impression that he does no more
than look, then shudder and turn away in distress, and
leave the work that he sees to be done there to some
good agency. Actually this is true in large measure and
will have to remain true. First, there will not be any-
where near the needed number of competent psychiatrists
in this country for the next hundred years. Second, a
psychiatrist often cannot do what his knowledge tells
him is the most important part of his work — work that
must be done by businessmen, schoolteachers, politicians
and labor leaders; for psychiatric thought which arose
from the careful study of a few who through their illness
made clear the foundations of human feeling and char-
acter, has left the patient and has spread to the consid-
eration of a sickly hostile world.

It is high time that some new light be cast on the
aggressions and hostilities of this world, which our feeble
moralizing and legislation have been so impotent to
check, for the atomic weapons now at hand are man’s
clear challenge to himself to survive or die. I do not
pretend that psychiatry has the answers nor that it alone
can save the world. No one knows better than a psy-
chiatrist how deep and firm are man’s destructive forces
nor how dependent a physician is upon the help of
others for the application of his knowledge, but in the
light of some of psychiatry’s knowledge our world should
be examined and the clear errors of the past corrected,
the outworn prejudices uprooted, and the common good
made evident to all. We can but try.

It is the family which is the basic unit of our society,
the hothouse for our children, and thus the background
for our men and women. It is in the emotional setting
of the family that some of the secrets of our adult be-
havior have been found, far more than we had any idea
of finding, and the more learned of the environmental
importance, the fewer character traits and emotional dif-
ficulties have been delegated to hereditary causes. One
of the most striking findings is the way in which a child
patterns himself on the character of the parent, a pat-
terning which is emotionally forced to give a confusing
pseudo-hereditary picture. In fact this process of pattern-
ing is an essential quality of growth itself and in a way
the parent lives on as an emotional part of the child.
Surprising as it may seem, this occurs just as readily
when the parent is far from an exemplary person as it
does when he or she is one. You may recognize this
quality in one of your friends who bitterly resented one
or the other of his or her parents and then with an un-
canny exactness duplicated many of the resented mother’s

Annual address given before the Cleveland Family Society,
May, 1946.

*Department of Psychiatry, Western Reserve University
School of Medicine, Cleveland, Ohio.

or father’s attributes or traits. A child is a helpless thing
who has no choice as to parentage, or as to models for
his development. It is an appalling fact in our society
that everyone must be examined if he is to be allowed
to drive a car, but that, examination or no, anyone can
have a baby. Most animal husbandmen spend years in
the scientific study of raising their stock. How many
parents prepare themselves properly for the rearing of
their children?

We are apt to think of environment in terms of
wealth or of poverty, in terms of neighborhood, or hous-
ing, but it is something more than that. A bad environ-
ment is likely to call to our minds a picture of squalor,
brutality or illiteracy. These things, of course, are bad
but there is a more subtle kind of bad environment of
just as much importance. We are all shocked and can
easily see the default when we read of a mother engaged
in wartime industry locking her small children out of
the house to do what they may while she works. We
are less aware of the emotional locking out of children
which many of us do on all social and intellectual levels.
Much of this neglect is sheer tragedy for parent, child,
and society and has its roots in many things. A surpris-
ing number of people have children for casual and per-
verted reasons; in the hopes that a child will mend a
breaking marriage; out of rivalry with a neighbor, or a
brother or a sister; in order to create an image of them-
selves so they can in a way live again, forcing the child
to fulfill the things they missed in life regardless of the
child’s desire; because of ignorance or neglect of birth
control; for the security and comfort that the children
will provide for them in their old age; for the extra
labor children give. All these reasons have one common
fault — the child is not regarded as a human being; as
an individual with desires, rights and abilities of its own
or as a great responsibility and pleasure. After birth
a child is often held responsible for his sex — one parent
or the other wanted the other kind. A girl late in her
third pregnancy, and in the third year of her wartime
marriage, which is more correctly described as the living
together of two immature people in a rivalry as to who
can take the most, said bitterly, "if this one isn’t a girl,
I’m through — I’ll give it away.” And she meant it.
Parents select their favorites and show it. They select
them often in accordance with their order of birth, their
appearance, or their charm. They line their children up
in family quarrels. A mother neglected by her husband
may try to substitute her son. One parent or the other
may be intensely jealous of the affection the other shows
toward a child or gets from it. A father is often so
busy doing "important” things that he never sees his
children at all. Most important of all they pass on their
own prejudices as facts. The sanctity of the home is still
inviolate — not unless people are financially destitute or
until a certain type of crime has been proved can a home

378

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be invaded by society. Physical neglect of a child is the
only charge allowed by most states before someone out-
side can legally step in. Physical neglect may be much
less harmful than emotional neglect and yet appalling
types of homes are allowed to discharge their distorted
products into society daily to marry and produce their
kind.

The importance of this today is that adult hostilities
and aggressions have their roots in childhood resentments
and it is in the understanding and the intelligent man-
agement of our children that some hope for a healthy
world may come. This is a terrific responsibility to place
upon parents and although I do not see how it can be
finally placed elsewhere, at least we can do something
to alleviate this burden. Mothers may be taxed too much
when there are many children, inadequate housing, no
help, or illness. It is very difficult to be a good and
thoughtful parent when you are worried about the exist-
ence of the next meal, the imperviousness of the roof,
and have a large family wash to do, when there is no
place for the children to play except under your feet,
and you are suspicious of your husband. These things
are easy to see, but it is just as hard to be a good mother
if your own life has taught you that motherhood is some-
thing to be taken for granted, that it doesn’t have the
dignity of a profession or an intellectual pursuit or isn’t
as worthy as trying to straighten out the lives of other
people; or if you didn’t really want your children; or if
you wanted them to make up for some unhappiness of
your own. In a word, being a parent becomes an enor-
mous task when you haven’t the capacity, born of emo-
tional maturity, happiness and some economic security
to enjoy your children. How many people plan their
lives so that their children will interfere with them as
little as possible; consign them to nurses for upbringing
while they take care of their house, join social clubs or
public-spirited organizations in order to live around their
children rather than with them.

While much of this criticism is aimed at mothers,
fathers should get their share. Too often the father ap-
pears in a child’s life in the role of a disciplinarian, as
if he were an extension of the arm of the law called on
to punish some mild delinquency, then fading into his
own nebulous background when the crisis is past. I have
already mentioned the importance of having a pattern
or an ideal as a guide for a child to grow on. It is a
distorted ideal indeed for the little boy who never sees
his father except at those times when punishment brings
them together. Recently I saw the mother of a severely
delinquent boy. His school had done everything possible
to help him. The mother entered the hospital because
she was depressed, sleepless, worried. She and her hus-
band had fought so constantly over his infidelity that
she had urged him to join the Army, which he had
done. Later he was reported missing in action and finally
his death was confirmed. His death hit her very hard,
as it often does in such circumstances. Her 12-year-old
boy remembered his father well and declared he was
going to be just like him. When she asked him why
he did things to hurt and upset her, she always got the
answer, "Well, he hurt you, didn’t he?” The boy in-

sisted on wearing his father’s clothes, and in assuming
his father’s manners. He objected violently to a long
line of suitors for his mother’s hand. Some of the rea-
sons for the child’s delinquency are not obscure. But
we should hesitate to pass moral judgments. If this de-
linquent boy had no chance, what chance had his par-
ents in their childhood? The mother was the sixth child
of an alcoholic mother and father who fought brutally
with each other throughout the years. The patient left
home and married and her first child was bom when she
was fifteen. The father was the son of a petty criminal
and his home was no more happy.

We all like to feel that our homes are our castles;
that in them we escape from public observation. We are
extremely sensitive about any intrusion as to bringing up
our children or getting along with our wives or husbands.
But hasn’t the day for this isolationism passed? We
have discarded this policy as a nation but we cling to it
bitterly in our own homes, and isn’t that really the more
fundamental concept? If the home is the breeding place
of the nation, shouldn’t it be subject to more scrutiny,
more thought and more effort than any other institution
we have? And shouldn’t the ability to run a good home
and to raise children with both a sense of freedom and
a sense of responsibility be the most dignified and hon-
ored occupation in our time?

As extension of the home and family the schools prob-
ably are of next importance in the molding of our lives.
Our teachers can have enormous influence in breaking
down prejudice, in pointing out the necessity and respon-
sibility of living together harmoniously and in helping
us to do it by example, in showing the real picture of
the world as it is and not as someone would like us to
believe for purposes of his own. History is taught today
with an emphasis on past differences, glorifying war
with an eye to falsely putting one’s own nation above
any other, regardless of fact. Even the outcome of
battles is falsely reported. Many sections and countries
are still fighting issues long since dead just as bitterly
as they did many years ago. I do not advocate a false
presentation of history or a deleted one, but an accurate
one with the emphasis upon the now neglected lessons
to be learned from the repeated common mistakes that
all nations have made — certainly the only real point of
any historical knowledge.

As to the teachers themselves, isn’t there some dis-
crepancy in our values when some of our teachers get
less than a thousand dollars a year for raising the hope
of tomorrow and a movie actor gets several hundred
thousand dollars a year? How can one obtain the quota
of well-balanced, intelligent, ambitious teachers we need
when of all the professions it is the most poorly re-
munerated? There are a few who can afford to make
this sacrifice but not many. The emphasis has been and
still is present in many communities to regard marriage
as a disqualification for teaching. Certainly there is no
more chastening nor enlightening experience for an
advisor on how to bring up children than to have a few
of his or her own.

There are two tendencies in the modern use of schools
that I would like to mention and condemn, for I feel

November, 1946

379

they are important. One concerns the way many par-
ents use schools as a place where they can unload their
children. They ask that the school keep the children all
day and keep them occupied so that they themselves will
be free of that responsibility. This tendency is perhaps
more marked in private schools where the functioning
depends to a somewhat greater degree upon the pleasure
of their patrons. Pupils here are often regimented to an
extraordinary degree and so burdened with the amount
of detailed knowledge required that they have little time
to live. Parents who do this not infrequently have chil-
dren whose school adjustment is far from satisfactory
and the teacher is often unjustly held responsible and
expected to cope with problems far beyond her scope.

Perhaps arising from this latter condition is the atti-
tude which is prevalent among teachers, some social
workers, and some physicians, that parents are unneces-
sary evils. An attempt is made to keep parents away
from the school because the children may get upset;
to have the parent interfere as little as possible in the
daily routine; to separate the child from the parent.
This attitude is striking in many hospitals and among
many others who deal with families, who, though serving
the interests of the child, lose sight of the enormous im-
portance of the parent to the child. Parents are certainly
necessary and even bad parents are very frequently better
than none. After all, children in hospitals and schools
return to the parents and this return must always be
kept in mind. Parents need education and teachers can
help them. Many parents are sincere and honestly try-
ing to understand their children better. Encouragement
along this line should be given and people who deal with
children directly must remember that the parents’ prob-
lem is an enormous one solved only with difficulty. Fur-
thermore, in the last analysis, parents are more impor-
tant in the child’s welfare than anyone else. Anyone
who has tried to remove a child from what they con-
sider a bad home will tell you of the difficulties involved.
Despite many obvious unhappinesses and hardships, the
child does not want to leave, and the parents, despite
their obvious rejection of him, are loath either to admit
their incompetence or to lose their child.

While schools are an extension of the family life and
teachers extensions of parents, they are no more than
that and it is seldom that they can take the formers’
place. They can provide help and respite to any mother
but they are aides. Schools can do much to modify ideas
of right and wrong, many of which are falsely imposed
by neurotic parents. They can do much with the author-
ity of their position and of their groups of children to
lessen guilt and tame aggression and open doors to
socially desirable outlets of enjoyment. Although lip
service is easily given to the concept that the social atti-
tude of the child is the most important aspect of his
school, his being thrown with others and forced to rec-
ognize that others exist and that he must adapt himself
to them is considered to be automatic. I think we all
agree that his social education is as important a part of
his schooling as anything else and many of us will agree
that it is the most important. It deserves far more
thought than it is given now as it should never be a

hit or miss proposition. It should be planned and it
should be subjected to the experimental method. As
much time should be given it as is given to the decision
of what textbooks to read. Although in larger cities the
standards for teachers are relatively high, in many com-
munities they are inadequate, and even in our best com-
munities teachers are not trained to understand the
complicated patterns of intellectual and emotional growth
of children. More emphasis is needed in this regard.
No one would be quicker to accept such training than
the teachers themselves who are often woefully bewil-
dered by the complicated problems of their pupils and
their families.

I think many of you will feel that this is a gloomy
and critical discussion, and in a way I think it should be.
I would like to say that I realize that there are excellent
parents and that many of our teachers do a remarkable
job. But in these times when we should all be searching
for the causes and reasons for war and the ways of
peace, I think it is important to turn our eyes on some
of those defects which we take for granted, which we
try to dismiss as someone else’s responsibility. A little
reflection will tell us all that many of the reasons for
war are only too evident. They are within each and
every one of us and the secrets for managing them and
turning them to constructive effort may not be so ob-
scure after all if we at least avoid many of the pitfalls
of our present and our past. This will not be easy, for
education in the field of emotions is a slow process and
takes a great deal of personal courage, but as someone
said, "The voice of the intellect is soft but it is per-
sistent.”

One of the great difficulties at this time is the over-
enthusiasm about psychotherapy and its effectiveness.
There are too few psychiatrists and this shortage cannot
be remedied in any reasonable length of time. Besides
that there are still more limitations. A person’s character
and his conscience are parts of him, just as is his arm
or leg, and when they are defective, it may be impossible
to correct them, let alone rebuild them. The conscience
in a way can be thought of as a person’s internal parent
who watches and guides thoughts and actions, for it is
formed largely by parental influence. When a defective
parent as an example becomes a real part of the child,
the child then has a defective part.

In a way it is of some value to think of the problem
of civilization in the light of the rearing of our children.
A child is born not only helpless but with many emo-
' tional demands that spurn compromise or delay. Emo-
tional maturing should take place in essence through
learning. From experience immediate gratifications are
often not found as satisfactory as they first seem, for
they may cause others so much pain that in the long run
suffering rather than enjoyment will result. This is the
first step, to learn that a long term goal is often more
desirable and satisfying than the quick gratification of
an impulse. We learn this first in regard to our imme-
diate families, then some of us can carry it further to a
small group, some to a large group, and a few to the
world. It is a difficult feat to keep pushing this principle
to larger and larger groups and farther and farther away

380

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from ourselves and we frequently fail. How striking it is
that a person’s social morals are better at home. Express-
ing desires to override and destroy, or to steal from a
member of one’s own family is abhorrent to most people,
but it is a little different with a big concern, one’s gov-
ernment, or another country. Despite our civilized front,
the little child impatiently demands "I want it and I
want it now and that is more important than anything
else in the world” and this philosophy underlies all the
economic and other reasons for war. It is men who cause
war and not external forces. It is our job in civilizing
our children to help them see that the simple principle
of long term gain is the same for all and it is our
responsibility to do our best to accomplish that end.

If we examine ourselves closely we will not be appalled
by the depth to which men fall during war for we will
see that in a more subtle way we have never risen very
high on the social scale. It is in the handling of our
families and our family affairs and in the raising of our
children and in creating and applying those things that
we already know from the study of people to our social
order that our chance for survival lies.

I would like to close with a quotation from the speech
by General Chisholm of the Canadian Army. "If now
we all revert to our little private concerns, if we all tell
ourselves 'it is someone else’s responsibility,’ there will
one day be none of us left, not even any to bury the
dead.”

COMMITMENT OF THE MENTALLY ILL

That errors and miscarriages of justice are possible even in these enlightened times and
notwithstanding the existence of statutes carefully safeguarding the liberty of the individual
against arbitrary or false commitment, is illustrated by an occasional case which has come
before the courts.

On the other hand, it is true that the statutory provisions of many of our states reflect a
point of view dating from a time when the institutions were regarded merely as places of
custody and restraint of liberty for fear of the harm their inmates might do if left at large.
The modern mental institution is a hospital, designed to treat and cure disease by the appli-
cation of medical science, and possessing facilities for promoting the mental and physical
comfort of the patients. Legislators have accepted this newer hospital view at least to the
extent of formally changing the name of the institutions from "insane asylums” to "state
hospitals” and by appropriating the funds to permit them to carry on their modern functions,
but this recognition has still not carried over to acceptance of the idea that the facilities of
these hospitals should be accessible to those who need their services as fully and freely as
other hospitals are available, without hindrance from unnecessary legal formality. The very
term "commitment” is an inheritance from the time when the insane were treated as dis-
orderly characters and committed to a jail, and in too many states the "commitment” pro-
cedure is still obviously patterned after that governing conviction of crime.

The problem, then, is to eliminate the legal requirements which serve no useful purpose
and which may even do harm, without sacrificing those legal safeguards necessary to protect
the liberties of the individual. To accomplish this end, it is necessary for the lawyers to rec-
ognize that commitment to a mental institution involves unique consideration not involved in
ordinary cases where the parties are presumably sane, and that the ordinary concepts of what
due process requires therefore do not necessarily apply. It is one thing to say that no (sane)
person’s rights should be legally determined without a hearing, of which he must be served
with notice and at which he must be given the right to attend and defend. It is quite another
matter to say that a person whose friends or relatives have petitioned to have him committed
to a mental institution, and whom two or more physicians have certified as requiring such
commitment, must be served with a legal notice that such proceedings have been commenced,
without regard for the effect which such a notice may have upon his condition, and must be
put to the experience of sitting through a legal hearing and listening to loved ones and the
family physician who perhaps has labored hard to win the patient’s confidence, testify to his
infirmities. The legal-minded reader will say, but suppose the person is actually sane, surely
he should be given notice and allowed to prove his sanity. The answer must, of course, be
in the affirmative; but the vast majority of commitment cases are not attempts to "railroad”
sane men into an institution. We need a procedure which will adequately protect the sane
without needlessly subjecting the sick to heartless and harmful mental torture. The ordinary
forms of judicial procedure are not adapted to accomplish this; a special procedure is called
for. — From "Commitment of the Mentally Insane,” W. Overholser, M.D., Sc.D., and
H. Weihofen, J.D., J.S.D., in Amer. Jour. Psychiatry, May, 1946.

November, 1946

381

Endogenous Toxic Encephalitis

A. B. Baker, M.D., and David Daly, M.D.*
Minneapolis, Minnesota

In contrast to the apparent resistance of the central
nervous system to many of the infectious agents, it
appears that the brain is particularly susceptible to the
action of most toxines which readily diffuse through the
blood-brain barrier to produce both clinical and patho-
logical changes. By far the most common of the cere-
bral toxins are exogenous in nature and include heavy
metals (arsenic, lead, mercury, manganese, gold, silver,
etc.), industrial organic solvents (benzine, carbon tetra-
chloride, tetrachlorethylene, aniline, alcohol, etc.) , drugs
(barbiturates, paraldehyde, sulfa drugs, opiates, etc.)
and some bacterial toxins (tetanus, diphtheria, botu-
linus) . Many of these exogenous toxins, particularly the
drugs and industrial solvents have been increasing in
importance particularly because of their use in various
branches of trade, industry and of daily life.

Amongst the cerebral toxins there is a much smaller
group of conditions in which the brain damage appar-
ently results from a toxin liberated within the human
body and not obtained from the outside. This group
has been called the endogenous toxic encephalitides and
includes the cerebral complications occurring in such con-
ditions as uremia, porphyria, eclampsia, liver damage,
burns, etc. The exact nature of the toxic agent is not
known in any of these diseases, but there can be no
question about the fact that some substance is liberated
in each that has a definite destructive action upon the
nervous system. The clinical picture usually suggests a
diffuse involvement of the brain while the pathological
changes are of a degenerative rather than an inflamma-
tory nature. The brain changes generally consist of
neuronal damage, vascular changes and focal or diffuse
myelin destruction. These findings are similar, in many
respects, to those seen in the exogenous toxins.

It is of interest to note that these endogenous toxic
encephalitides complicate diseases which fall into the
sphere of a wide variety of medical specialties; thus em-
phasizing the overlapping of the field of neurology with
many other branches of medicine.

Uremia

It has long been recognized that in uremia there oc-
curs an autointoxication that may result in damage to
many of the body tissues. Since some of the most com-
mon symptoms in this disease, namely, the convulsions
and the lethargy, indicate cerebral involvement, it at
once becomes apparent that the central nervous system
does represent at least one of the most important regions
of toxic injury. The importance of the cerebral damage
in this illness as related to the widespread clinical symp-
tomatology was well recognized in the older literature,
but seems to have been ignored in many of the recent
writings.

The symptoms of uremia can be divided roughly in

*From the Division of Neurology, University of Minnesota
Medical School, Minneapolis.

two groups: those of depression of the central nervous
system, e.g., apathy, muscular weakness, stupor and
coma; and those of neuromuscular hyperexcitability with
increased tendon jerks, muscular twitchings and convul-
sions. The former are by far the most common and ap-
pear earliest in the illness. The patient may appear men-
tally and physically fatigued, tiring easily and being un-
able to concentrate. Dull, constant but not severe head-
aches may develop. The patient Soon becomes apathetic
and complains of muscular weakness and a constant feel-
ing of drowsiness, while at the same time he may have
periods of restlessness and intractable insomnia. Cloud-
ing of the sensorium, although occurring, is not the rule,
many of the patients remaining well oriented until death.
The speech, however, may be difficult and often un-
intelligible.

Symptoms of neuromuscular hyperexcitability, namely,
muscular twitchings and convulsions, are very frequent
in uremia and often accompany the picture of lethargy,
stupor or coma. The muscular twitchings are usually
fibrillary in nature and may involve large muscle groups.
The convulsions usually appear terminally and are gen-
eralized in nature. Focal or Jacksonian seizures may
occur but are uncommon. Occasionally these epileptiform
seizures continue even after the patient has recovered
from the uremia, indicating the persistence of cortical
irritation or brain damage.

Aside from these better known neurological symptoms,
there occurs in uremia a host of less common and often
bizarre findings that frequently cover the entire field of
neuropsychiatric symptomatology. It is when these pre-
dominate that the diagnosis is often overlooked. Most
frequent are the vague and often unusual neurological
syndromes. Monoplegias, hemiplegias, aphasias and
apraxias have been reported. Of the motor symptoms,
hemiplegia is most frequent. This usually is of a flaccid
type and is often ascending, producing a Landry’s type
of paralysis. The involvement is transient, lasting hours
or days and then disappearing only to return after a
variable period. Two of our cases revealed such episodes;
in one of them the involvement implicated all limbs,
resulting in a quadriplegia. Miller and Michalovici 1
described a case in a 26-year-old male who developed
a right-sided hemiplegia with a left facial palsy. Roth-
mann " described a case of transient amaurosis. This
amaurosis may be associated with convulsions and may
even remain as a permanent defect. Uremic deafness
may occur. Vertigo and nystagmus are infrequent
symptoms.

In an occasional case of uremia the mental symptoms
may be the earliest and often the predominating ones
throughout the illness. The most frequent picture con-
sists of an acute confusion associated with motor unrest,
incoherence and terrifying hallucinations. Occasionally
there is a rapid mood change from an uncontrollable
hyperactivity to a depression accompanied by hypochon-

382

The Journal-Lancet

driasis and delusions of persecution. Almost every form
of mental illness has been described in uremia from pro-
found melancholia to typical catalepsy with echolalia,
negativism and waxy flexibility. Mental deterioration
may occur and can be transient or permanent depending
upon the severity of the cerebral injury.

Since the cerebral symptomatology is not specific but
merely indicates some type of nervous system involve-
ment, one must always seek for any additional symptoms
or signs that might help in the diagnosis. These are fre-
quently found in the accompanying gastrointestinal
symptoms and the alterations in the blood chemistry.
The gastrointestinal symptoms usually consist of a uremic
stomatitis, a uriniferous odor of the breath, vomiting and
diarrhea. The changes in the blood chemistry are well
known and need no discussion.

In a recent investigation we had the opportunity of
studying the brain changes in seven cases of uremia. It
was at once apparent that this disease produces severe
and often irreversible changes within the cerebral tissues.
The type of alteration varied with the duration of the
illness. In the acute cases the predominant damage oc-
curred within the cortical neurons which showed the
typical picture of acute nerve cell damage. In the more
chronic illness the most striking changes were paren-
chymal rather than neuronal and consisted of focal and
perivascular areas of demyelinization and necrosis. The
neurons showed both acute and chronic changes in the
more prolonged illness, many of the cells appearing as
tiny dark masses within which none of the cell structures
could be identified.

The etiology of the cerebral complications in uremia
still remains a moot question in spite of extensive investi-
gations. The experimental data thus far accumulated
would indicate that the uremic syndrome is either the
result of a disturbance of electrolytes, an increase in the
nitrogenous metabolites within the blood or the evolution
of some toxin hitherto unrecognized. This latter view
finds some corroboration in the work of Foster,3 who
was able to isolate a crystalline substance from uremic
blood which, when injected intraperitoneally into guinea-
pigs, produced paralysis, convulsions and death. Unfor-
tunately, this work has not as yet been confirmed.

The work of Harrison and Mason 4 would indicate
that in uremia the brain is subjected to two antagonistic
influences, one stimulating, the other depressing in na-
ture. According to these investigators, the increased
neuromuscular irritability is apparently due to more than
a deficit of ionized calcium, as injections of a suitable
calcium salt will not always alleviate the symptoms.
De Wesselow 5 and Harrison and Mason1 found no
connections between the diminution of serum calcium
and the generalized convulsions. Becher 0 and de Wes-
selow '' placed a greater prognostic value on the rise in
serum phosphates than the deficit of calcium.

The depression in nervous system functions in uremia
has been suspected by some to be due to a rise in blood
phenols. (Dickes,1 Becher0 and Mason, et al.8). These
authors do not agree as to whether the phenols must be
free or can be combined. Certainly chronic phenol poi-

soning produces a clinical picture resembling some cases
of uremia.

More recently a great deal of interest has been cen-
tered upon the significance of altered potassium levels
within the blood of uremic patients. The recent work of
Brown, Currens and Marchand 9 seems to indicate that
too high a level of blood potassium is as dangerous as
too little. Cardiac arrest may develop from either. The
changes in the electrocardiograph may be helpful in such
cases.

Porphyria

Porphyria, although a relatively rare condition, is of
interest to the neuropsychiatrist and neuropathologist
because it frequently results in extensive damage to the
nervous system. As a matter of fact, the nervous system
involvement may comprise the predominant symptom-
atology, often obscuring the fundamental nature of the
disease process.

The clinical picture of porphyria is most variable and
is often confused with variants of other well known
neuropsychiatric disorders. Most frequently affected seem
to be the peripheral nerves, resulting in the development
of a motor weakness primarily of the lower limbs. The
weakness is flaccid in type and usually ascends slowly
to involve the upper extremities. In the fatal cases, the
disease ascends to the brain stem, resulting in dysphagia,
dysarthria and finally death from medullary paralysis.
In most cases, the peripheral nerves reveal an extensive
patchy degeneration of both the myelin sheaths and the
axons. Mason and his associates 10 also observed collec-
tions of lymphocytes around scattered vessels within the
nerve trunks.

In porphyria there may occur a wide variety of both
neurological and psychiatric manifestations often entirely
independent of the lower motor neuron involvement,
thus indicating definite cerebral damage. The neuro-
logical findings that have been reported suggest a dif-
fuse and extensive involvement of the nervous system
(headaches, hyperactive knee jerks, ataxia, nystagmus,
pupillary irregularities, facial twitchings, somnolence,
convulsions, etc.) . Of these the convulsive seizures are
the most frequent and have been described by many
investigators. Almost as frequent as the neurological
symptoms are the marked and variable mental disturb-
ances. These may appear as a toxic delirium with rest-
lessness, irritability, hallucinations and delusions; as a
severe depression often with suicidal tendencies; or as
an acute manic excitement. In view of the definite clin-
ical manifestations of cerebral involvement, it is some-
what surprising that so few reports are available describ-
ing histopathologic alterations in the brain. That such
changes, reversible or irreversible, should occur would
seem most probable in view of the clinical picture.

Neuropathologic studies reported by Baker and Wat-
son 11 and a few other investigators 12,13 indicate clearly
that in addition to the changes already described in the
peripheral nerves there occurs also a diffuse damage to
the central nervous system itself. This is manifested by
patchy areas of nerve cell degeneration consisting of
chromatolysis and cellular swelling together with scat-
tered foci of perivascular demyelinization.

November, 1946

383

Although the exact nature of the toxic substance in
porphyria is thus undetermined, there can be little doubt
that some product of the abnormal metabolism is in
many cases capable of producing actual nervous system
damage. The frequency and nature of the peripheral
nerve involvement is well known. This portion of the
nervous system, no doubt, carries the brunt of the attack,
often giving rise to permanent sequelae in the nature of
atrophies, contractures, trophic changes, etc. However,
insufficient emphasis has been given to the brain changes
in this disease. A careful survey of the reported cases
reveals that many of the patients, at some time during
their illness, do develop evidence of scattered cerebral
lesions. Most of these changes must be reversible since
the clinical manifestations usually clear up during the
remissions. However, in the presence of such profound
neurological and psychiatric phenomena, it seems in-
evitable that some irreversible tissue alterations should
occur. And, as a matter of fact, damage to the central
nervous system is not so uncommon as the sporadic re-
ports would lead one to believe. From a review of the
literature and a study of our own cases, it is apparent
that repeated attacks of porphyria may produce a de-
generation of brain tissues and cells, resulting in slow
recovery or even in permanent functional damage. The
frequency with which such structural alterations will be
found will no doubt vary with the intensity of the histo-
pathological studies.

Eclampsia

The occurrence of convulsions as a dreaded complica-
tion of pregnancy has been recognized since ancient
times. It is mentioned in the writings of the Egyptians,
Greeks, and Chinese. In the last century the subject of
eclampsia has become one of intense interest to obstetri-
cians and others. A tremendous mass of literature has
accumulated regarding its symptomatology, etiology and
pathology. Nevertheless, in spite of the fact that cere-
bral involvement is one of the outstanding symptoms,
surprisingly little is known about the central nervous
system pathology.

Typically, eclampsia occurs as a convulsion or series of
convulsions appearing near term. It is usually preceded
by certain premonitory signs including hypertension,
albuminuria and edema. As the disease progresses, cere-
bral symptoms become apparent. These include head-
aches, tinnitus, drowsiness, delirium, confusion, stupor
and coma. Visual disturbances, particularly in the form
of scotomata, are frequent. Amaurosis occurs in occa-
sional cases. The convulsion is usually generalized in
character with tonic and clonic phases. It is indistinguish-
able in character from the grand mal seizures of idio-
pathic epilepsy. Following the seizure, the patient is
stuperous or comatose for a varying period of time just
as is noted following convulsions from other causes.
According to Dieckmann,14 amnesia for twenty-four
hours or more following the convulsion occurs in 40 per
cent of the cases. Eclampsia without convulsions may
occur. In these cases the patient suddenly passes into
coma and frequently expires. In the absence of convul-
sions antemortem diagnosis of eclampsia is often not
made. Although it is extremely rare, eclampsia may

occur without convulsions or coma. Only a few such
cases have been reported.

There are several complications of toxemias of preg-
nancy. One of the most frequent is a cerebrovascular
accident. This may be either thrombosis or hemorrhage.
About one hundred such cases have been described
with an over-all mortality much higher than that of an
uncomplicated toxemia. Infrequently a toxic psychosis
may supervene either in severe pre-eclampsia or between
convulsions in eclampsia. The development of a post-
partum psychosis following eclampsia can occur but is
uncommon. The rarest complication of all is epileptic
seizures persisting after eclampsia. Only three such
cases have been reported.

The pathology of eclampsia requires further elucida-
tion. Schmorl 15 described diffuse petechial hemorrhages
and areas of focal necrosis. Sioli 10 reported thromboses,
perivascular hemorrhages and degenerative changes in
the vascular endothelium. Diamond 17 observed degen-
eration of the ganglion cells, diffuse glial proliferation,
meningeal infiltration by cellular elements and reactive
phenomenon in the vascular system in addition to the
changes already described. It would seem that the most
constant and wide-spread alterations consist of nerve cell
degeneration, demyelinization, glial proliferation and
proliferative endarteritis. Such pathologic changes sug-
gest strongly the presence of a toxin disseminated widely
throughout the central nervous system by a vascular
route. Although no such agent has been identified at
present, it is the feeling of many investigators that the
pathologic lesions of eclampsia are the consequence of
the complex interaction of multiple factors, among them
being an unidentified endogenous toxin.

Burns

In recent years improvements in the immediate treat-
ment of extensive body burns have made it possible for
patients to survive the initial phase of shock. Never-
theless, many of these patients succumb in the next two
or three days during what is often referred to as the
"toxemic” phase of burns. At this time patients fre-
quently exhibit signs of severe cerebral involvement.
These patients may suddenly develop restlessness leading
to manic excitement, confusion, disorientation or drowsi-
ness and apathy which may progress to stupor and
finally coma. Late sequelae may develop weeks or
months after a severe burn. These include convulsions,
amaurosis, aphasia, movement disorders and personality
changes. Hydrocephalus and cortical atrophy may be
demonstrated by pneumoencephalography.

Kruse 18 reported the case of a 15-month-old child
who suffered extensive second-degree burns of the trunk.
At first the child appeared to be recovering, but after
about four weeks it suddenly developed fever, convul-
sions and blindness. Repeated pneumoencephalograms
revealed a progressive hydrocephalus. The blindness dis-
appeared after another month but the child remained
mentally deficient.

Globus and Bender 19 reported the case of an eight-
year-old boy who sustained severe second-degree burns
of the extremities and face. This patient showed no
objective neurologic findings at any time but did show

384

The Journal-Lancet

personality changes in the subsequent months. He died
after six months and at autopsy severe degenerative
encephalopathy was found.

Pathologic studies of this condition are not numerous.
Walker and Shenkin 20 described severe nerve cell de-
generation with ghost cell formation in the cortex and
hypothalamus, and marked dilatation of the pericellular
and perivascular spaces. Globus and Bender 1!) reported
a case dying after six months with extensive demyeliniza-
tion and gliosis.

At the present time studies in this field are insufficient
to permit a definitive statement on the pathogenesis of
these lesions. It has been customary to attribute the
picture to shock and anoxia; however, more recent work
has shaken this concept. In many case anoxia is absent
altogether or present in such minimal degree as to be
insufficient to explain the clinical picture of cerebral
damage. The pathological picture is more consistent
with an endogenous toxic damage. In support of this
hypothesis is the experimental evidence of brain damage
produced in guinea-pigs by the injection of extracts
from burned tissue. In addition there is some evidence
to suggest that the serum of burned dogs contains a
toxic substance or substances which is injurious to
normal dogs.

Liver Disease

A frequent and well recognized manifestation of ter-
minal hepatic failure is the onset of coma. The whole
problem of the interrelationship between hepatic and
cerebral damage is quite obscure even at this time. The
problem was given impetus by Wilson’s description in
1912 of the familial occurrence of portal cirrhosis and
lenticular degeneration. Since then, there has accumu-
lated experimental data, some of which is conflicting, on
cerebral alterations produced by liver damage. By the
use of Eck’s fistula in dogs it has been possible to pro-
duce signs of cerebral involvement including ataxia, trem-
ors, twitchings, amaurosis and coma. The neuropatho-
logic picture found is one of focal necroses and nerve
cell degeneration. De Jong 21 has been able to produce
what he terms "experimental catatonia” in dogs either
by means of ligation of the hepatic artery or of an Eck’s
fistula. Crandall and Weil 22 ligated the common bile
ducts or the pancreatic ducts of dogs and were able to
demonstrate the appearance on the fourth day of sub-
stances in the serum which were destructive to the spinal
cords of rats in vitro. These substances were not lipases.
The brains of the dogs showed spongy necrosis of the
ventricular walls, diffuse nerve cell damage, demyeliniza-
tion and glial proliferation. It was their opinion that
these toxins were disseminated via the choroid plexus or
the walls of the cerebral vessels.

The clinical manifestations of cerebral damage, other
than coma, in chronic liver disease are usually not well
described. However, in a series of unpublished cases
which we have observed we have seen several bizarre
neuropsychiatric pictures including pyramidal tract dis-
turbances, Parkinsonian rigidity and facies, perseveration
and echolalia, decerebrate rigidity and a thalamic-like
syndrome. Neuropathologic studies in some of these
cases revealed diffuse ganglion cell degeneration and

widespread severe demyelinization which tended to be
perivascular in character. At the present time further
studies are planned to clarify the nature of this process.
We are convinced that it is due to the hematogenous
spread of substances normally detoxified by the liver.

Discussion

In this brief review, no attempt has been made to cover the
entire field of the endogenous toxic encephalitides. It is appar-
ent from our studies that these toxins play an important role in
the production of cerebral damage and that they should be
given more attention in the final evaluation of many of the more
unusual neuropsychiatric involvements. With our increasing
knowledge of body metabolism it is probable that more and
more of these endogenous toxins will be uncovered and that
their effect upon the nervous system will be of prominent im-
portance in the final outcome of any therapeutic procedure in-
stituted. It is hoped that the present report will stimulate inter-
est in the occurrence and recognition of these various forms of
encephalitis and that through more careful and more constant
evaluation of cerebral function, many instances of the milder
cerebral involvements will be recognized.

Bibliography

1. Hiller, F., and Michalovici, E.: Lesions organiques cere-
brales au cours de 1’uremic. Schweiz. Arch. f. Neurol, u. Psy-
chiat., 46:203, 1941.

2. Rothmann, M.: Ueber die transitorische Erblindung bei
Uramie. Klin. Wchnschr., 31:691, 1894.

3. Foster, N. B.: The Isolation of a Toxic Substance from
Blood of Uremic Patients. Tr. A. Am. Physicians 30:305, 1915.

4. Harrison, T. R., and Mason, M. T.: The Pathogenesis
of the Uremic Syndrome. Medicine, 16:1, 1937.

5. de Wesselow, O. L. V.: On Phosphorus and Calcium of
the Blood in Renal Disease. Quart. J. Med., 16:341, 1923.

6. Becher, E.: Studien iiber die Pathogenese der echten

Uramie, insbesondere iiber die Bedeutung der retinierten Phe-
nole und anderer Darmfaulnis-produkte, Zentralbl. f. inn. med.
46:369, 1925.

7. Dickes, R.: Relation Between the Symptoms of Uremia
and the Blood Levels of Phenols. Arch. Int. Med. 69:446, 1942.

8. Mason, M. F., Resnick, H., Minot, A. S., Rainey, J.,
Pilcher, C., and Harrison, T. R.: Mechanism of Experimental
Uremia. Arch. Int. Med., 60:312, 1937.

9. Brown, M. R., Currens, J. H., and Marchand, J. F.:
Muscular Paralysis and Electrocardiographic Abnormalities Re-
sulting from Potassium Loss in Chronic Nephritis. J.A.M.A.,
124:545, 1944.

10. Mason, V. R., Courville, C., and Ziskind, E.: Porphyrins
in Human Disease. Medicine, 12:355, 1933.

11. Baker, A. B., and Watson, C. J.: Central Nervous Sys-
tem in Porphyria. J. Neuropath, and Exp. Neurol., 4:68, 1945.

12. Courcous, A., Lhermitte, J., and Boulanger-Pillet: La

paralysie extenso-progressive Rematoporphyrique. Press med.,
2:1609, 1929.

13. Golden, L. A.: Hematoporphyrinuria Neuritis. Am. J.
Med. Sc., 206:474, 1943.

14. Dieckmann, W. J.: Toxemias of Pregnancy. St. Louis,
1941.

15. Schmorl, W.: Zur Lehre von der Eklampsie. Arch. f.
Gynak., 65:504, 1902.

16. Sioli: cited by Diamond.

17. Diamond, I. B.: Puerperal Eclampsie. A Neuropatho-

logic Study. Arch. Neurol, and Psychiat., 35:1320, 1936.

18. Kruse, F.: Encephalitis und Amaurose nach Verbren-

nung. Deutsch. med. Wochensch., 54:1039, 1938.

19. Globus, J. H., and Bender, M. B.: Disseminated Toxic
Degenerative Encephalopathy (Disseminated Sclerosing Demy-
elinization) Secondary to Severe and Extensive Burns. Jour.
Nerv. and Ment. Dis., 83:518, 1936.

20. Walker, J., and Shenkin, H.: Studies on the Toxemic

Syndrome after Burns, II. Central Nervous System as a Cause
of Death. Ann. Surg., 121:301, 1945.

21. De Jong, H. H : Experimental Catatonia. Baltimore,

1945.

22. Crandall, L. A., and Weil, A.: Pathology of Central

Nervous System in Diseases of the Liver. Arch. Neurol, and
Psychiat., 29:1066, 1933.

November, 1946

385

Occlusions of Arteries Supplying the
Brain-Stem and Cerebellum

John E. Skogland, M.D.

Houston, Texas

In contrast to occlusions of cerebral arteries vascular
lesions of the brain-stem and cerebellum are uncom-
mon. The purpose of this paper is to review certain
established syndromes resulting from occlusions of ar-
teries supplying the medulla oblongata, pons, and cere-
bellum, and to cite the relative incidence of these lesions
over a nine year period (1935 through 1943) at the
Charity Hospital of Louisiana in New Orleans.*
Anatomy

To facilitate an understanding of vascular lesions of
the brain-stem and cerebellum, the anatomical relations
of important blood vessels will be described.1 The two
vertebral arteries which carry blood into the posterior
fossa of the cranial cavity arise on either side from the
subclavian arteries and pass upward along the antero-
lateral surfaces of the medulla oblongata, finally cours-
ing medially to join at the lower border of the pons.
By their union these form the basilar artery which con-
tinues up in the midline anteriorly, finally to bifurcate
at the upper border of the pons into the posterior cere-
bral arteries which enter into formation of the Circle
of Willis. Just below its termination each vertebral
artery gives off an important branch, the anterior spinal
artery, which courses downward and medially anterior
to the medulla oblongata. The two vessels unite in the
vicinity of the lower end of the medulla to form a single
anterior spinal artery which descends along the anterior
median fissure to the ventral aspect of the spinal cord.
The posterior spinal arteries arise either from the ver-
tebral or from the posterior inferior cerebellar arteries
and extend caudally to reach the posterior surface of the
spinal cord. The largest branch of the vertebral is gen-
erally the posterior inferior cerebellar artery; this arises
at the lower border of the olive and ascends in the
neighborhood of the postero-lateral sulcus almost to the
lower border of the pons, then loops posteriorly to de-
scend along the infero-lateral wall of the fourth ven-
tricle, reaching the inferior surface of the cerebellum.
It divides into medial and lateral branches. The anterior
inferior cerebellar and superior cerebellar arteries origi-
nate from the basilar artery. The former comes off from
the basilar a little above its point of origin, passes lat-
erally across the pons and over the brachium pontis to
supply the anterior portion of the inferior surface of the
cerebellum. The superior cerebellar artery arises just
below the level at which the basilar bifurcates into the
posterior cerebral arteries, courses laterally and posteri-
orly over the pons, finally to reach the superior surface
of the cerebellum where it divides into medial and lat-
eral branches. After reaching the cerebellum, all these

*The author was formerly assistant professor of neuropsy-
chiatry at Louisiana State University Medical School and visit-
ing physician at the Charity Hospital of Louisiana in New
Orleans.

vessels anastomose freely and send collaterals into the
deeper parts.

The vascular supply of the medulla oblongata is de-
rived from the anterior spinal, posterior inferior cere-
bellar, vertebral and basilar arteries. The pyramids, in-
cluding the decessation, medial lemnisci, and hypoglossal
nuclei are major structures supplied by the anterior
spinal arteries. Each posterior spinal artery distributes
blood to the nuclei gracilis and cuneatus as well as to
the caudal and dorsal parts of the restiform body. There
has been a great deal of attention given the problem of
the blood supply of the lateral area of the medulla ob-
longata. The general belief has been that the posterior
inferior cerebellar artery nurtures all of this region lying
between the inferior olivary nucleus and the restiform
body. Recent investigations cast some doubt upon that
concept. Foix, Hillemand and Schalit 2 describe a branch
of the basilar artery, termed the artery of the lateral
fossa, which they claim supplies a large wedge shaped
area in the lateral portion of the medulla. To some ex-
tent, the studies of Alexander and Suh 1 are confirma-
tory. These authors identified the same vessel arising
from the basilar artery and demonstrated that, as a rule,
it distributes blood to the anterior portion of the lateral
medullary area, while more posteriorly this region was
nourished by a branch from the posterior inferior cere-
bellar artery supplemented by a few direct branches from
the vertebral artery.

The pons receives its blood supply from the basilar,
superior cerebellar and anterior inferior cerebellar ar-
teries. Numerous slender branches springing from the
basilar artery pass backward to supply the central sub-
stance of the pons. Branches from the superior cere-
bellar artery reach the upper dorsolateral portion of the
pons. At a lower level the lateral portion of the pons is
nourished by the anterior inferior cerebellar artery.

There is known to be considerable variation in the
arrangement and distribution of these vessels. Moreover,
branches are not always symmetrical or equal in caliber.
Not infrequently the vertebral arteries have a very short
course, fusing to form the basilar at an unusually low
level. In such a circumstance it has been observed that
direct branches from the basilar may supply structures
located in the medial portion of the medulla. Union
of the vertebral arteries at some distance above the lower
border of the pons is a rare variation. Except for the
aforementioned differences in its level of origin, the
course of the basilar artery has been found fairly con-
stant. The site at which the anterior spinal artery springs
from the vertebral is greatly variable. In numerous in-
stances branches from the two sides fail to fuse, though
generally transverse communications exist between the
vessels. The anterior spinal artery occasionally is absent
on one side. The area ordinarily supplied by it is then

386

The Journal-Lancet

nourished by the vertebral artery. Anomalies of the
posterior inferior cerebellar artery are especially common.
It may arise from the basilar instead of from the ver-
tebral artery. Occasionally the vessel originates on one
side from the vertebral artery and on the other side from
the basilar artery. Sometimes the posterior inferior cere-
bellar artery is absent on one side; less frequently it is
absent on both sides. When such an arrangement exists,
this vessel is replaced in the supply of the medulla ob-
longata by branches from the vertebral artery. The loop
made by the vessel on the lateral aspect of the brain-stem
varies in form. In a small proportion of cases the loop
is not present and the artery passes directly outward to
the cerebellum. At times the anterior inferior cerebellar
artery springs from the vertebral. Absence of this vessel
also has been reported. In other cases it has been found
to have origin from the lower end of the basilar in com-
mon with the posterior inferior cerebellar artery. Anom-
alies of the superior cerebellar artery are uncommon.
Rarely, the vessel is absent and is replaced by branches
from the posterior cerebral artery.

Pathology

Occlusions of arteries supplying the brain-stem and
cerebellum result from the same pathological processes
which account for cerebral vascular insults. The most
common cause is thrombosis, generally developing on
the basis of arteriosclerosis, though occasionally resulting
from vascular neurosyphilis. At times obstruction is
caused by an embolus, arising most often from an endo-
carditis. Hemorrhage into the brain-stem, unrelated to
trauma, occurs infrequently.

Following obstruction of a vessel the segment of brain
irrigated by it undergoes prompt softening and degenera-
tion. Anastomoses between collaterals of various vessels
are too poor through the brain-stem to permit much com-
pensation for a diminution in blood supply. In contrast,
branches of these arteries reaching the cerebellum anas-
tomose so freely that, as an aftermath of occlusion, there
is comparatively little destruction of the cerebellar sub-
stance.

Posterior Inferior Cerebellar Artery

The earliest references to the syndrome of the pos-
terior inferior cerebellar artery were made by Senator,4,0
Remak,*’ and Wallenberg.7,8 The latter is generally cred-
ited with the first detailed description of the symptom-
atology, and as a consequence the syndrome resulting
from occlusion of the posterior inferior cerebellar artery
has been termed the Wallenberg syndrome. Recently
Romano and Merritt n have pointed out that the descrip-
tion of his own case made in 1810 by Gaspard Vieus-
seux, though not diagnosed specifically then, corresponds
closely with the classical picture of thrombosis of the
posterior inferior cerebellar artery.

This is the most common of the vascular lesions to be
reviewed here. Though every neurologist occasionally
encounters a case of this type in his practice, a dispropor-
tionately small number have been reported in medical lit-
erature. Gerard10 found 39 cases reported prior to 1923.
In a survey of literature published between that date and
1937, Sheehan and Smyth11 collected another 22 cases

and added 2 of their own. Subsequently more than a
dozen additional cases have been reported.

A review by the author of the records at Charity Hos-
pital revealed that four patients presenting the syndrome
of the posterior inferior cerebellar artery were admitted
during the years 1935 through 1943. In all instances
this was a clinical diagnosis; no deaths occurred in the
group.

Symptoms resulting from thrombosis of the posterior
inferior cerebellar artery are fairly uniform.12,13 The
onset usually is sudden, though there may be a period
during which an increase in severity of symptoms is no-
ticed. Consciousness is not lost. Vertigo is a prominent
feature and is explainable on the basis of involvement
of the vestibular nuclei. Vomiting also may occur. Oc-
casionally when the cochlear nuclei are involved, deaf-
ness develops on the side of the lesion. Dysphagia is
common, caused by paralysis of the soft palate and lar-
ynx on the side of the lesion resulting from involvement
of the nucleus ambiguus. If there also is vocal cord
paralysis, the voice will be hoarse. Pain or paraesthesiae
referred along the distribution of the trigeminal nerve
on the side of the lesion reflect some irritation of its
sensory pathways. With involvement of the restiform
body incoordination develops ipsilaterally and there is
a tendency to fall toward the side of the lesion.

In addition to the above phenomena, neurological ex-
amination characteristically reveals the following: Im-

pairment of sensibility to pain and temperature over the
trunk and extremities on the side opposite the lesion as
a result of involvement of the lateral spinothalamic tract.
Occasionally the disturbance in pain and temperature
sensation extends upward on the opposite side to include
the face. This is an indication of interference with con-
duction through the ventral central trigeminal tract.
Tactile sensibility remains normal, and usually there is
no interference with deep sensibility. Nystagmus is prom-
inent, especially on deviation of the eyes toward the side
of the lesion. It results from implication within the
medulla of fibers connecting the vestibular with the ocu-
lomotor nuclei. Diplopia may exist. Horner’s syndrome,
resulting from involvement of the intramedullary sym-
pathetic pathway, is evident ipsilaterally. Myosis is the
most frequently encountered manifestation, ptosis is seen
less often, while enophthalmos is very rare.

Significantly, there is no paralysis of the extremities,
facial muscles or tongue.

The prognosis is generally good and in most instances
slow recovery ensues.

Vertebral Artery

Occlusion of a vertebral artery, sometimes designated
the Babinski-Nageotte syndrome, is rarely recognized by
the clinician.

Only a single case of thrombosis of the vertebral ar-
tery was discovered in reviewing the Charity Hospital
records from 1935 through 1943. This was a clinical
diagnosis.

It has proved difficult to distinguish clinically between
occlusions of the vertebral and the posterior inferior cere-
bellar arteries.11,14 Cases have been reported in which
the classical symptomatology of thrombosis of the pos-

November, 1946

387

terior inferior cerebellar artery existed, yet at necropsy
thrombosis of the vertebral artery was discovered.

The most commonly emphasized basis for differentia-
tion between these lesions is occurrence of weakness in
the tongue, trunk or extremities. Typically, there is in-
volvement of the pyramidal tract in thrombosis of the
vertebral artery. Thus, in addition to symptoms referable
to infarction of the lateral medullary region, varying
degrees of muscular weakness and hyper-reflexia are
found contralateral to the lesion. However, lack of evi-
dence of pyramidal tract involvement cannot be offered
as conclusive proof that an occlusion is confined to the
posterior inferior cerebellar artery. Other ground for
differentiation evolves from the observation that the pos-
terior inferior cerebellar artery never supplies the spino-
thalamic tract below the lower border of the nucleus
ambiguus; hence, crossed and dissociated anesthesia with-
out dysphagia or laryngeal paralysis is indicative of
occlusion of the vertebral artery.

Anterior Spinal Artery

Because it is commonly accompanied by involvement
of other vessels, notably the posterior inferior cerebellar
or the vertebral artery, occlusion of the anterior spinal
artery is seldom diagnosed. No patient admitted to
Charity Hospital during the years covered by the present
review was given such a diagnosis.

Following thrombosis of the anterior spinal artery
there is destruction in the medulla oblongata of one or
both pyramids, the medial lemiscus and occasionally
fibers of the hypoglossal nerve.15

In the classical syndrome there develops on the oppo-
site side of the body weakness and hyper-reflexia, to-
gether with loss of deep or discriminative sensibility. In
some instances paralysis and atrophy of the tongue occur
ipsilaterally. Nystagmus may exist when the area of in-
farction includes the posterior longitudinal bundle. Bi-
lateral involvement of the pyramidal tracts and medial
Iemnisci may be expected if the two anterior spinal ar-
teries have united close to their origin.

Superior Cerebellar Artery

The syndrome of the superior cerebellar artery was
first described by Mills 16 in 1908. Freeman 17 in 1941
was able to find reports of 22 cases. No patient admitted
to Charity Hospital during the years of this review re-
ceived such a diagnosis.

The classical components of the syndrome include
homolateral signs of cerebellar dysfunction, as well as
impairment in pain and temperature sensation over the
opposite side of the body.

Cerebellar signs include ataxia, adiadokokinesia, dys-
arthria, hypotonia and rebound phenomenon. Involun-
tary movements, involving especially the upper extremity,
are a prominent feature. Intention tremor exists and
nystagmus may be present. These symptoms and signs
are explained by involvement of the cerebellar hemi-
sphere, brachium conjunctivum and dentate nucleus.
An explanation for the observation that symptoms are
more prominent in the upper than in the lower ex-
tremity lies in the fact that the superior surface of the
cerebellar hemisphere exercises control over movements
of the upper extremity while the inferior surface, sup-

plied by the anterior inferior cerebellar artery, influences
movement of the lower extremity.

Contralateral impairment in pain and temperature sen-
sation, including face, trunk, and extremities, results
from degeneration of the spinothalamic tract passing
through the dorsolateral region of the pontile tegmen-
tum. Fibers carrying other forms of sensation have a
more medial position and derive blood from pontile
branches of the basilar artery.

Occasionally there are signs indicating slight pyra-
midal tract involvement; reflex changes and weakness in
the extremities have been noted. In several instances the
sixth or seventh cranial nerves have shown weakness.
Occurrence of pyramidal tract signs or cranial nerve
palsies suggests some anomaly of the superior cerebellar
artery.

Basilar Artery

Reference is made to 17 cases of thrombosis of the
basilar artery in a review published in 1932 by the Rus-
sian authors, Pines and Gilinsky.1* Scattered case re-
ports have appeared subsequently.

In the present review of Charity Hospital records,
3 cases of thrombosis of the basilar artery, all verified
at autopsy, were encountered. Unfortunately, the clin-
ical work-up in each case was incomplete, and no de-
tailed neuropathological studies were made. Nevertheless,
since this lesion is rare, all three cases are abstracted
below.

The clinical syndrome associated with thrombosis of
the basilar artery has not been clearly defined. There is
variation in the symptomatology depending upon the
level at which the artery is occluded. Pyramidal tract
signs, unilateral or bilateral, stand out as the most con-
sistent feature. Convulsions have been reported. Cranial
nerve palsies may occur. It has been suggested that
cranial nerve dysfunction is a manifestation of pseudo-
bulbar palsy resulting from bilateral pyramidal tract in-
volvement, since infarction in the pons does not gen-
erally extend to include cranial nerve nuclei. Tempera-
ture elevation is typical. Coma usually develops a short
while after onset of symptoms, and there is a fatal ter-
mination within several days.

It is of special interest to note that in a great ma-
jority of the reported cases syphilis has been the cause of
thrombosis of the basilar artery.

Case 1. (T -39-35967) . 56 year old colored male, admitted
8-1-39 and died 8-3-39. Illness began 7-25-39 with dizziness
and ataxia. Shortly after onset noticed numbness in right hand.
Later speech became indistinct, he had difficulty using the left
upper limb and there was weakness of the left side of the face.
Steady progression of symptoms. Passed into coma 7-31-39.
Review of past history revealed that he was treated at Charity
Hospital in 1934 and again in 1937 for luetic heart disease with
decompensation. Blood Wassermann was known to be positive
since 1934.

Respiration was of the Cheyne-Stokes type. Blood pressure
186/100. Pulse was 115 to 120. Temperature 104.2 degrees
on entry, rising terminally to 105.6 degrees. There was slight
ptosis on the left. Paralysis of the left side of the face, the
tongue and the left upper extremity was noted. No other ab-
normalities were recorded. The blood Wassermann reaction
was positive. Spinal fluid examination, including the Wasser-
mann, was entirely normal.

At autopsy (A-39-824) only gross study of the brain was
made. A thrombosis of the basilar artery was found 1 cm.

388

The Journal-Lancet

above its formation by the vertebrals; secondary softening of
the right side of the pons was evident.

Case 2. (T-39-12595) . 67 year old white female, admitted

3-17-39 and died the same day. Onset of illness the morning
of entry, when she could not be aroused from sleep. No other
symptoms elicited. Had diabetes for years, and because of
gangrene right leg had to be amputated in 1938.

On admission she was comatose and generally flaccid. Pupils
were constricted. Respirations were slow. No fever until just
before death when temperature rose to 102.6 degrees. Blood
pressure 160/80, changing later to 200/75. Pulse varied between
80 and 95. No blood or spinal fluid Wassermann test was
made.

Autopsy (A-39-312) revealed recent thrombosis of the basilar
artery with extensive softening through the pons, mid-brain and
cerebellum. Detailed microscopic examination was not reported.

Case 3. (6315). 40 year old colored female, admitted

2-6-35 and died 2-12-35. In coma on entry, and no history
was obtainable.

Temperature, 99 degrees, rising terminally to 104 degrees.
Blood pressure 150/80. Remained comatose. All tendon re-
flexes were hyperactive. The extent of paralysis that existed is
not clearly recorded. Blood and spinal fluid Wassermann tests
strongly positive.

Gross examination of the brain at autopsy revealed throm-
bosis of the basilar artery near its bifurcation into the posterior
cerebral arteries. There was extensive softening through the
pons. No pathological change was recognized in the medulla
oblongata or cerebellum.

Summary

Because of the infrequency with which thrombosis of
arteries supplying the brain-stem and cerebellum is en-
countered, the associated clinical syndromes are not gen-
erally familiar and may pass unrecognized. In the fore-
going review syndromes associated with thrombosis in
five principal arteries are described. The close correla-
tion between clinical symptoms and distribution of path-
ological changes is emphasized. The incidence of such
vascular lesions in a large general hospital is mentioned.

Bibliography

1. Stopford, J. S. B.: The Arteries of the Pons and Me-
dulla Oblongata. J. Anat. & Physiol., 50:131 and 255, 1916;
51:250, 1917.

2. Foix, C. L., Hillemand, P., and Schalit, I.: Sur le syn-
drome lateral du bulbe et l’irrigation du bulbe superieur:

L’artere de la fossette laterale du bulbe, le syndrome dit de la
cerebelleuse inferieute, territoire de ces arteres. Rev. neurol.,
32:160, 1925.

3. Alexander, L., and Suh, T. H.: Arterial Supply of Lat-
eral Paraolivary Area of the Medulla Oblongata in Man. Arch.
Neurol. & Psychiat., 38:1243, 1937.

4. Senator, H.: Apoplektische Bulbarparalyse mit wechsel-
standiger Empfindungslahmung. Arch. f. Psychiat., 11:713,
1881.

5. Senator, H.: Zur Diagnostik der Herderkrankungen in
der Brucke und dem verlangerten Mark. Arch. f. Psychiat.,
14:643, 1883.

6. Remak, R.: Krankenvorstellung eines Falles vom Hemi-
anaesthesia alterans. Berl. Klin. Wchnschr., 18:300, 1881.

7. Wallenberg, A.: Acute Bulbaraffektion (Embolie der
Art. cerebelli post. inf. sin.). Arch. f. Psychiat., 23:504, 1895.

8. Wallenberg, A.: Anatomischer Befund in einem als
akute Bulbaraffektion (Emolie der Art. cerebelli post. inf. sin.?)
beschriebenen Fall. Arch. f. Psychiat., 34:923, 1901.

9. Romano, J., and Merritt, H. H.: Singular Affection of
Gaspard Vieusseux: Early Description of Lateral Medullary
Syndrome. Bull. Hist. Med., 9:72, 1941.

10. Gerard, M. W.: Afferent Impulses of the Trigeminal
Nerve: The Intramedullary Course of the Painful, Thermal
and Tactile Impulses. Arch. Neurol. & Psychiat., 9:306, 1923.

11. Sheehan, D., and Smyth, G. E.: A Study of the Anat-
omy of Vertebral Thrombosis: With Reports on Two Cases.
Lancet (London), 2:614, 1937.

12. Merrit, H., and Finland, M.: Vascular Lesions of the
Hind-Brain (Lateral Medullary Syndrome). Brain, 53:290,
1930.

13. Thompson, R. H.: Occlusion of the Posterior Inferior
Cerebellar Artery: A Clinical Study of Four Cases. Arch.
Neurol. & Psychiat., 22:530, 1929.

14. Ramsbottom, A., and Stopford, J. S. B.: Occlusion of
the Posterior Inferior Cerebellar Artery. Brit. M. J., 1:364,
1924.

15. Davison, C.: Syndrome of the Anterior Spinal Artery
of the Medulla Oblongata. Arch. Neurol. & Psychiat., 37:91,
1937.

16. Mills, C. K.: Hemianesthesia to Pain and Temperature
and Loss of Emotional Expression on the Right Side with
Ataxia of the Upper Limb on the Left. J. Nerv. & Ment. Dis.,
35:331, 1908.

17. Freeman, W., and Jaffe, D.: Occlusion of the Superior
Cerebellar Artery. Arch. Neurol. & Psychiat., 46:115, 1941.

18. Pines, L., and Gilinsky, E.: Ueber die Thrombose der

Arteria basilaris und ueber die Vascularisation der Brucke.
Arch. f. Psychiat., 97:380, 1932.

NATIONAL MENTAL HEALTH INSTITUTE TO BE CONSTRUCTED

The Public Health Service has asked for an appropria-
tion of $5,200,000 for the development of the National
Program provided by the Mental Health Act recently
adopted by congress. $850,000 of this amount will be
used for starting construction of a National Mental
Health Institute at Bethesda, Maryland. The building
of this institute is expected ultimately to cost $7,500,000.
It will include a 200 bed hospital for study of nervous
and mental diseases and will serve as a center of psy-
chiatric research and training.

Members of the National Mental Health Advisory
Council appointed by Surgeon General Thomas Parran
to aid and advise in the development of the program are
Drs. W. C. Menninger of Topeka, Kansas; John Ro-

mano, Professor of Psychiatry at the Rochester Univer-
sity Medical School; Edward A. Strecker of Philadel-
phia; Frank F. Tallman, Mental Hygiene Commissioner
of the state of Ohio; David M. Levy, Child Psychiatrist,
New York; George S. Stevenson, Medical Director of
the National Committee for Mental Hygiene, New
York.

Dr. Parran has also appointed four consultants to the
Council: Drs. S. Alan Challman of Minneapolis; Wil-
liam Malamud of Boston; Frank Fremont-Smith and
Nolan D. C. Lewis of New York. Dr. Robert H. Felix,
Chief of the Public Health Service’s Mental Hygiene
Division, is in charge of the overall program. — From
New York Medicine, Sept. 20, 1946.

November, 1946

389

Psychiatric Care in Hospitals

L. R. Gowan, M.D., M.S.

Duluth, Minnesota

We have just passed through the acute stage of a
great world war. National crises have always
focused the attention of our nation to the importance
of a citizenry, stable enough and adaptable enough to
meet the needs of the hour, both in dependable materials
and resourceful manpower. War brings out both man’s
strength and his weakness by threatening his collective
and individual security. The mobilization of a great
armed force olfers an opportunity for taking an inven-
tory of our nation’s health. As a result we are awakened
from a state of more or less complacency to a point of
making great effort to overcome our exposed deficiencies.
War exposes the weaknesses of the mental health of a
nation far more than it does its physical health. In spite
of the fact that we enjoy the best health of any nation
in the world, it is the natural reaction of the American
people to wish to raise our health standards even higher.

Psychiatry made great strides forward during and fol-
lowing World War I. It is advancing with a more rapid,
steadier stride at the present time as a result of the
impetus received from World War II. During the past
few years several thousand physicians, serving in the
armed forces, came in contact for the first time with or-
ganized psychiatric departments functioning as special
units in general hospitals. They have witnessed first
hand what can be accomplished by close cooperation of
medical, surgical, and psychiatric sections. They had on
innumerable occasions experiences with patients with
problems, outwardly organic in nature, but later proven
to be psychogenic. They have recognized the profound
effects of emotional stress on the development of dis-
turbed physiological states, some of which produced irre-
versible organic lesions. They learned to diligently search
the background of every patient, seeking to formulate
the early emotional pattern which under increased stress
led to the production of an emotional or organic illness.
For example, they learned to objectively study every psy-
chiatric patient presenting the complaint of abdominal
distress and as a result, 75 per cent of all patients in the
gastro-intestinal department of one of our service hospi-
tals were referred to that department from the psychi-
atric section. Many of these physicians were given spe-
cial training in psychiatry. Most of them will continue
in the field after seeking more adequate training. These
men know what psychosomatic medicine means. They
know the significance of early mental symptoms. They
are tuned in, as it were, for continued interest and a
useful career in caring for emotionally disturbed people.

The social dislocations which accompany war have
focused the attention of the press and radio on the re-
sulting psychiatric problem. The nation is aware of the
existence of psychiatry and what it means as never
before. Psychiatry has touched the lives directly or in-

Read before the annual meeting of the Midwest Hospital
Association, Kansas City, Mo., April 25, 1946.

directly of more of our citizens than ever before.

The time is at hand for stabilizing these advances and
taking advantage of this recognition, so that the nation
as a whole can benefit from better mental health through
prevention of mental illness and more adequate care for
those suffering from abnormal mental conditions. Those
of us whose duty it is to administer to the sick in our
offices, clinics and hospitals, must see to it that no citizen
suffering from mental illness lacks proper professional
direction and hospital care. The increasing number of
people in this country recognized as needing care for
emotional disturbances is too great to hope for their ade-
quate care in existing state and federal institutions and
private sanitaria, including all the proposed additional
beds to be made available in the near future.

It has been estimated that 35 to 65 per cent of the
problems presenting themselves to the average general
practitioner requires psychiatric understanding. Strecker1
has stated that 75 per cent of the clientele of the general
practitioner during the first ten years of his professional
life consists of the neuroses, organic disturbances compli-
cated by neurotic conditions, psychopathological compli-
cations of chronic organic disease, the mental aspect of
convalescence, and partial or complete psychopathological
problems in children.

Rees and Billings 2 determined that in the state of
Colorado alone there were from three thousand to nine
thousand patients annually admitted to general hospitals,
the majority of whom were admitted with physical diag-
nosis and were not known to be psychiatric patients at
the time of admission. Heldt,8 a pioneer in general hos-
pital care of psychiatric patients estimates that, "From
12 to 20 per cent of all patients admitted to a general
hospital will be found to present conditions and problems
that are primarily neuropsychiatric regardless of the pa-
tient’s complaint or the diagnostic impression on first
contact. If mention be made, as well, of all cases show-
ing secondary and minor disturbances of nervous organi-
zation the percentage promptly rises to 30 per cent and
higher.”

Ebaugh 4 states that very few general hospitals have
provisions to care for the mental patients, and "those
that do not have the facilities will not let you bring a
nervous and mental patient into them — if they know it.
In spite of this attitude every hospital admits psychiatric
patients without knowing it and they are usually treated
without any consideration for the psychiatric issues.”

"No doubt exists at the present time as to the urgent
need for the provision in general hospitals of early treat-
ment facilities for psychiatric patients. In every com-
munity and every county and state in the nation, there
are hundreds and thousands of these individuals seeking
care, ready and willing to pay for it and not finding
hospital or medical facilities provided.”

With the advent of shock therapy for mental diseases,
first insulin, then metrazol, and later electroshock, the

390

The Journal-Lancet

therapeutic armamentarium of psychiatric care has risen
to a plane of usefulness and practicability on a level with
that of general medicine and surgery. With proper selec-
tion of patients and therapy, the period of hospital care
required to bring about cure or improvement sufficient to
allow the patient to return home has been greatly short-
ened. In fact, in many instances less hospital care is
required for acute mental states than for many medical
and surgical patients with as great or greater expecta-
tion for returning to their homes and living a useful life.
The expense of the former long period of extended hos-
pital care has been reduced so greatly as to bring private
hospital mental care well within the pocketbook of many
families who formerly could not have provided such care.

In addition to providing treatment for those cases
admitted to the hospital with a known mental illness,
a special psychiatric department offers an additional serv-
ice to every other department in the hospital. From day
to day in any general hospital there are many cases de-
veloping mental disturbances that either were not recog-
nized at the time of entry or developed later as a com-
plication of a medical, surgical, or obstetrical condition.
Severe febrile states, particularly in elderly people, fre-
quently are accompanied by acute mental upsets requir-
ing protection and special care. Acute postoperative and
postpuerperal mental states are too well known to elab-
orate on. These are best taken care of in a special de-
partment and at much less expense to the family. Eye
cases requiring several days of postoperative darkness are
prone to become readily upset mentally. Acute traumatic
cases, especially head injuries, frequently have more or
less prolonged periods of confusion, excitement, and de-
lirium. These cases cannot safely be given sufficient seda-
tion to keep them quiet and under control and can be
best cared for, if not actually in a special department,
at least by a staff of nurses who know how to use hydro-
therapy and other nonhypnotic means of controlling a
clouded brain. If for no other reason than practicability,
general hospitals of the country must prepare to take
care of psychiatric patients.

One of the greatest drawbacks to the understanding
and provision of adequate care for mental illness has
been the still existent bug-bear that to be mentally ill
puts a stigma upon the patient and his family. There
is nothing that will tear down this belief more quickly
or more surely than to have people become better ac-
quainted with mental illness. This can be done by hav-
ing each community educated through their local gen-
eral hospitals. To have mentally ill patients whisked
away to some distant hospital, away from their homes
and families only augments the idea that they in some
way must be to blame for allowing themselves to become
mentally ill, thus bringing disgrace to their families.
Removal to the friendly atmosphere of a general hos-
pital in their own home community not only has a bene-
ficial influence on the welfare of the patient, but is much
less disturbing to his family as well.

Marked advances have been made especially in the
last decade in the recognition of the part that emotional
disturbances play in the development of physical illness,
and/or in the delay of their recovery. Many excellent

articles, monographs, and texts have been written on the
subject of psychosomatic medicine. Much stress is being
laid on the teaching of psychiatry and related conditions
in our medical schools. The development of special psy-
chiatric departments in general hospitals throughout the
country will furnish a medium of training for hundreds
of young doctors who otherwise could not possibly gain
adequate insight and understanding of borderline and
frank mental illnesses. Such a department must be an
integral part of the hospital. It must not be considered
something apart from the hospital as a whole. The
attending staff in the psychiatric department must accept
the opportunity to teach both resident and general med-
ical and surgical staff at every opportunity, otherwise
they will not be fulfilling their duty toward the advance-
ment of psychiatry and the raising of the standards of
psychiatric care in their community.

A special psychiatric section should be open to all
staff members for admission of their patients, but con-
sultations with trained psychiatrists should be the rule.
Treatment procedures should be under the direction of
qualified psychiatrists only. Unless this is done the de-
partment will be most difficult to run efficiently and
many patients will be given inappropriate or inadequate
treatment; incorrect diagnoses will be made and the de-
partment will not accomplish its true purpose, which is
correct diagnosis and proper treatment. By closely align-
ing the activities of such a department with the rest of
the hospital much interest can be aroused on the part of
non-psychiatrists, and mutual benefit will result.

The presence of special psychiatric departments in
general hospitals makes for better care for many patients
in whom complicating physical diseases may be present.
The first requisite of adequate care for a mentally ill
patient is a thorough physical examination. With com-
petent internists, surgeons, and others always available
as consultants, the psychiatrist can make certain that he
is not overlooking a contributing or causal physical factor
in the production of the mental illness. Complete labora-
tory facilities also add to the ease with which a mental
patient can be carefully studied. General hospitals hav-
ing approved internships and residencies lessen the load
of work required on the part of the psychiatrists, allow-
ing more time for personal interviewing and personal
application to the problems at hand.

Ebaugh 4 points out that "instead of being merely a
specialty, psychiatry must be looked on as a fundamental
of general medical practice, assuming a place along the
side of anatomy, physiology, pathology and therapy on
the one hand, and representing a major clinical division
of medicine on the other. Psychiatry is that phase of
medicine which deals with the therapy of the person.
Behavior reactions on the part of a person are not neces-
sarily wholly in nature of ideas, emotions or moods, but
very often include important somatic physiological and
even organic aspects which can be understood in terms
of a physical approach."

Adequate psychiatric training and experience cannot
be obtained in medical school days alone. The hope of
the future lies in having every physician recognize the
part that emotions play in the development of somatic

November, 1946

391

disease, and being ready to recognize incipient mental
disturbances and accept the responsibility of providing
prompt and adequate treatment. Without psychiatric
departments in general hospitals with available psychi-
atric consultants this cannot be achieved.

Every experienced psychiatrist knows too well the diffi-
culty encountered in attempting to care for a psychiatric
patient in a general hospital that does not have the nec-
essary facilities to care for such a patient. From the
administrative heads, the nursing staff, and even from
an unsympathetic, misunderstanding medical staff, psy-
chiatrists in such a general hospital are exposed to lifted
eyebrows, signs of irritation and other evidences of being
a culprit in attempting to care for a mentally ill patient
outside of an asylum. The slightest commotion, incon-
venience, or noise caused by such a patient practically
calls for a general court-martial, although there may be
many times as much noise and commotion from the nur-
sery, obstetrical, or surgical floors. The family of the
unfortunate patient is beseeched to remove him elsewhere
though they may be loath to do so. Or else they must
provide round-the-clock special nursing which they may
be unable to do without great financial hardship. On
the contrary, any psychiatrist who has had experience in
treating mental patients in a special department of a
general hospital can testify to the feeling of complete
acceptance of such a patient on the part of the adminis-
trative, nursing, and medical staff.

As one who has witnessed the evolution and growth of
a special department for the treatment of mental patients
in a general hospital, let me relate some of my experi-
ences.

For many years, the administrative heads of St. Mary’s
Hospital, Duluth, Minnesota, the Sisters of St. Bene-
dict, recognized the need of supplying better community
service by opening their doors to those who were men-
tally ill. These patients were treated and observed for
varying periods of time. Some remained only a short
time until further provision could be made for them.
Others quickly adjusted to general hospital care and re-
mained until recovery was complete. There was, how-
ever, a feeling of inadequate protection, insufficient
trained nursing supervision, and a lack of acceptance
on the part of many. In 1934, plans were afoot for
some alterations and improvements in a first floor wing
in this hospital. Because of an already favorable atti-
tude, it took little urging on the part of the writer to
have this wing set aside for a psychiatric section. Ac-
cordingly, with little structural change needed, eleven
private rooms were made available with protected win-
dows, completely closed off from the rest of the hospital.
Later a recreational sitting room was provided by com-
bining an adjoining clothes room and an unused elevator
area which had for many years been waste space. Shortly
thereafter a continuous tub room was added. In addi-
tion to the closed section there are many other rooms
on an adjoining first floor wing that are used freely for
the psychiatric patients who do not need the protection
of a guarded department, but who nevertheless do need
special psychiatric care. The total number of available
beds fluctuates somewhat, but the daily average number

of strictly psychiatric patients in this hospital is close
to fifty. These patients are primarily acute cases requir-
ing and receiving active psychiatric care. Cases of senility
and other chronic, organic psychiatric or borderline men-
tal cases requiring only custodial care are not placed in
these beds if it can be possibly avoided. These beds are
reserved for psychiatric cases requiring active care. In
the present time of crowded hospital conditions there
is always a waiting list.

This department is not ideal by any means as yet.
Many needed improvements, such as type of window
screens, recessed heating, etc., have not been installed
because of an impending building program which calls
for a completely modern psychiatric division. Neverthe-
less, in spite of the lack of some of the niceties of
modern architectural refinement and conveniences, the
department has done yeoman service. It has served the
community in such a fashion as to allow this hospital
to hold its head a little higher and deserve the name
of being truly a general hospital, for how can a hos-
pital be considered a general hospital when it excludes
certain types of patients? This department has steadily
increased in usefulness. In 1945 the department cared
for three times as many patients as it did in 1935. The
number of consultations requested of the psychiatrists
in attendance has increased in the same ratio. The de-
partment is thoroughly accepted as a necessary and use-
ful addition to the general service which the hospital
offers the community. This special section has furnished
teaching material for interns, residents, and nurses.
It has quickened the interest of the general staff to no
little degree. It has taken its rightful place in producing
enlightening and instructive case study material for
monthly staff meetings. But what is more important,
it has cared for mentally ill people at a time favorable
for their recovery. It has done so at a minimum of ex-
pense to their families who have been close enough at
hand to feel that they have contributed something more
than money to the recovery of their loved ones. These
families have a better understanding, less emotional
reaction, and greater acceptance of the experience be-
cause a general hospital which takes care of the phys-
ically sick was willing and prepared to administer to
the mentally sick as well.

Summary

I can summarize this paper most fittingly by again
quoting from Dr. Ebaugh,4 "The establishment of psy-
chiatric facilities in a general hospital brings substantial
benefits to the hospital, the community, the patient, and
the medical profession. The hospital gains economically,
becomes truly general, raises the level of medical prac-
tice within its walls, improves relationships with the com-
munity, saves money for everyone concerned, and be-
comes capable of competently discharging important edu-
cational responsibility to nurses, medical students, interns,
and residents. The community gains through the acqui-
sition of local complete medical and hospital facilities,
by saving money in transportation, hospital bills, social
maladjustments, and the expense of unnecessary chron-
icity through the availability of early treatment facilities
not otherwise available and through the opportunity to

392

The Journal-Lancet

learn a constructive mental hygiene through teaching
and practical demonstration. The patient gains through
the opportunity of receiving complete early care easily
accessible to his home with no stigma attached, and is
saved from incomplete approaches with long periods of
observation and diagnostic study because effective thera-
peutic help is available at home. The medical profession
is offered the advantage of a stimulating bilateral con-
sultation arrangement, acquires a broader concept of
medicine and therapy, including psychotherapy, combats
the need for irregular practitioners, acquires broader
research facilities, and allows the private physician to
retain and care for cases he would otherwise send away.
Psychiatry is given an opportunity to demonstrate the
value of early attention, methods of modern therapy,

and the application of constructive mental hygiene prin-
ciples. Its unhealthy isolation is removed, and old ideas
of 'insanity’ are dissipated by the demonstration that its
patients can be studied as objectively, efficiently, and sci-
entifically as those in any other branch of medicine.”

Bibliography

1. Strecker, E. A.: Psychiatric Education. Paper read be-
fore the International Congress on Mental Hygiene. Ment.
Hyg., 14:797-812.

2. Rees, M., and Billings, E. G.: Care of the Neurotic
Patient in a General Hospital. Hospitals, 11:21 (Aug.), 1937.

3. Heldt, Thos. J.: The Mental Hygiene Viewpoint in the
General Hospital. Ment. Hyg., 17:208-217 (April), 1933.

4. Ebaugh, Franklin G.: The Care of the Psychiatric Pa-
tient in General Hospitals. American Hospital Association,
Chicago, 1940.

Book JUvUm

Surgical Treatment of the Nervous System, by F. W.
Bancroft, M.D., and C. Pilcher, M.D. Philadelphia: J. B.
Lippincott Co., 1946, 534 pages, illustrated. $18.00.

This volume comprises the first attempt of presenting a sur-
vey of the advances in the surgical treatment of the nervous
system. The book is beautifully written and well illustrated.
Each of the chapters is handled by a different author who has
approached his subject in his own way. This naturally makes
for considerable variation in style and in approach to the sub-
ject. In spite of this large group of contributors all the sections
are brief, concise, well written and make for excellent reading.

Probably the greatest single weakness in this work is the fact
that many of the authors have covered their subjects from an
individual standpoint and have not included a comprehensive
review of the entire field so as to allow this volume to be used
as an adequate reference book in neurosurgery. One notices also
that certain types of neurosurgery have been omitted, such as
techniques and procedures in psycho-surgery.

Special attention might be called to certain chapters in this
volume which are extremely outstanding. The section by Peet
and Echols on surgical disorders of the cranial nerves is one of
the best in the book. This particular chapter clearly covers the
entire field in a simplified, comprehensive but still detailed man-
ner. One can highly recommend this chapter as one of the
finest written on this subject. Another excellent chapter has
been written by White on surgery of the sympathetic nervous
system.

In general, one might say that this volume can be highly rec-
ommended for the use of the undergraduate or even the post-
graduate student in neurosurgery. It certainly does not seem to
be comprehensive enough to take the place of a reference book
in this field. A. B. B.

Psychotherapy in General Medicine, by Geddes Smith,
Associate, The Commonwealth Fund, New York, 1946.
Available in quantity for free distribution by medical schools,
medical societies, and public agencies. Single copies, twenty-
five cents.

Presented in this report are the results of an experimental
postgraduate course on Psychotherapy in General Practice at the
Center for Continuation Study of the University of Minnesota.
This course was attended by twenty-five physicians during the
first two weeks of April, 1946, and was sponsored jointly by
the Commonwealth Fund and the Division of Postgraduate Ed-
ucation of the University of Minnesota.

Lectures and general seminars included: General Orientation,
Patient-Physician Relationship, Normal Personality Develop-
ment, Meaning of a Psychoneurosis, Diagnosis of a Psycho-

neurosis, Anxiety, General Principles of Psychotherapy, Special
Therapies, Common Psychopathology, Sex Education and Mar-
riage Counseling, Care of Veterans, Physiological Functioning
as Affected by Emotions, and case presentations.

In this report the author has outlined the course and de-
scribed it from every angle, including comments by the partici-
pants. The general consensus is that the experiment was a suc-
cess and a rewarding experience for both students and in-
structors.

Toward Mental Health, by George Thorman. Public Af-
fairs Pamphlet No. 120, prepared in cooperation with the
National Mental Health Foundation. New York, 1946.
32 pages. 10 cents.

A program of popular mass education on mental health has
been launched by the Public Affairs Committee, Inc., of New
York and the National Mental Health Foundation of Phila-
delphia, a non-profit educational organization. The campaign
is designed to educate the American public to a sound and
sympathetic approach toward mental illness, and to aid in its
early recognition and treatment.

The pamphlet discusses fears, nervous indigestion, moodiness,
and other emotional sicknesses in everyday terms. The person-
alized facts in the pamphlet summarize valuable wartime re-
search and have been checked by a panel of leading mental
health authorities. The summary advocates a three-point action
program: (1) Help by acquainting yourself with the truth

about mental illness — how it develops, how it is treated, and
how it can be prevented. (2) Join with others in the fight
against nervous and mental disorders by supporting those or-
ganizations that are working for the improvement of mental
institutions, pressing for enlightened legislation, and helping to
establish centers for prevention, treatment, and research. (3)
See to it that your community provides facilities for prevention
and early treatment. Good hospitals and clinics come only
when an enlightened citizenry sees the need for them and is
willing to spend the money it takes to operate them.

SUBSCRIPTION RATE CHANGE
Effective with the January 1947 issue, the beginning
of the 77th year of this journal’s publication, the sub-
scription rate will be advanced to $3 per year. This is
made necessary by increased costs of paper and printing.
During the last fifteen years the publication has grown
from a 48-page journal to one running from 80 to 102
pages each issue. Six to ten professional papers per issue,
written by authorities — against four or five in an earlier
day — provide readers with a variety and high quality of
content. The editorials are noted for the maturity and
soundness of their views.

New subscribers remitting before December 31, 1946,
and current subscribers renewing may enjoy the $2 rate
through 1947. To others the rate will be $3.

November, 1946

393

Huntington’s Chorea in Relation to the Heredity
of Personality Disorders

Burtrum C. Schiele, M.D.*

Minneapolis, Minnesota

Huntington’s chorea has created interest far out of
proportion to its numerical importance. Such in-
terest stems largely from the fact that the disorder is
a relatively clear-cut clinical entity and that it has cer-
tain hereditary characteristics which make it a promising
field for the study of human genetics. It is the only
psychotic state which is clearly hereditary and which may
at times present the clinical picture of a "functional”
psychosis.

Huntington,1,2 and most of those who followed him,
have listed the classical characteristics of the disease as:
(1) Onset in middle or late life; (2) a characteristic
chorea; (3) dementia; (4) progressive course; (5) hered-
itary nature.

While these statements are accurate in the main, fur-
ther study has necessitated their modification and has
revealed important additional facts. The essential char-
acteristics as they are understood today will be briefly
described with special emphasis on certain points which
are either of special importance or about which there is
conflicting opinion or widespread misconception.

Age of Onset

Insidious development makes it difficult to determine
the exact time of onset. However, this is usually taken
to mean the age at which the disorder becomes frankly
manifest.

The classical statement that most cases become appar-
ent at or after age 35 is only partly true. Statistics on
several large series of cases 1 indicate that one fourth
begin before the age of 30 and one tenth begin before
the age of 20. Although the vast majority have their
onset between the ages of 25 and 50, apparently authen-
tic cases have been reported with the onset as early as
4 and as late as 70.

The Chorea

The characteristic chorea is usually easily distinguished
from Sydenham’s chorea in that it is coarse, and involves
the trunk and large joints bilaterally. The abnormal
movements either develop gradually out of a general
restlessness and clumsiness or may appear first localized
in the hands, face, head, or some other region. In severe
cases the chorea progresses to involve virtually all the
voluntary musculature of the body, swallowing becomes
difficult and speech unintelligible.

As with most tremors, the movements are made worse
when attention is focused upon them and they disappear
during sleep. They do not respond to drugs. Aside from
the abnormal movements there are no positive neuro-
logic or physical findings. Motor power is good. Ex-
tensive laboratory studies have been negative.4

The Personality Disorder
Very little is known regarding the nature of the pre-

*Department of Psychiatry, University of Minnesota.

psychotic or pre-choreic personality. Evidently many are
good-natured, even-tempered, ambitious, successful,
"normal” people before the onset of the symptoms.
Others are characterized as "always” having been un-
stable and temperamental. It would be of importance to
establish clearly the characteristics of the pre-psychotic
make-up of choreic individuals, but this is difficult for
many reasons including the fact the prodromal symp-
toms of the personality disorder grow insidiously out of
the basic personality traits and are difficult to distinguish
from the latter. The first evidences of the personality
disorder are usually nervousness, restlessness, discontent-
ment, and emotional instability.

The established personality disorder may vary greatly
from case to case. The following rough groups may be
distinguished:

(a) Mild personality changes with slow, if any, pro-
gression. Intellectual loss is slight, and interest declines,
but the patient is not grossly deviant. Such cases usually
can get along well outside of an institution.

(b) Cases in which the personality disorder resembles
the "functional” psychoses. The clinical picture, at least
for some time, does not show evidence of the organic
pattern; that is the memory, orientation, and intellect are
intact. Instead the clinical picture may show predom-
inant mood changes — manic excitement, depression with
self-depreciation, guilt feelings and suicide; or it may
show paranoid delusions, hallucinations, and queer be-
havior. Such a picture may continue for years before
the sensorium defects become evident. Needless to say,
many of these patients are mistakenly diagnosed as hav-
ing schizophrenia or manic-depressive psychosis.

(c) The dementing type. This variety shows early
development of memory defects, dullness, narrowing of
comprehension, and poor judgment. The habits deteri-
orate, subtly at first; the subjects become careless in dress
and work. Inhibitions are released, leading to disregard
for social convention. Irritability is usually marked, vio-
lent emotional outbursts are common, as are instances
of assaultiveness.

It is evident that there are no definitely distinguishing
features to the mental picture of Huntington’s chorea.
The symptoms of an organic type of psychosis, especially
the memory defects and intellectual dulling, eventually
appear in most cases. For many years, however, a patient
may present a clinical picture which is not readily dis-
tinguished from one of the functional psychoses, or in
the case of milder choreics from the psychoneuroses or
psychopathic personalities.

Diagnosis presents no difficulties in the fully developed
case, especially if there is a positive family history. Very
rarely a toxic or degenerative disease of the brain (such
as senility) may cause abnormal involuntary movements

394

The Journal-Lancet

suggesting this type of chorea. The most common and
by far the most important diagnostic problem, however,
concerns the patients who develop the personality disor-
ders before the onset of the chorea.

The chorea is recognized before, or simultaneously
with, the psychosis in about 75 per cent of the cases.
It may exist for many years before gross mental changes
appear. In approximately 25 per cent of the cases, the
personality disturbance appears first, commonly preced-
ing the chorea by four to six years, although an extreme
of nineteen years has been recorded. In exceptional cases
the chorea may be very slight, and it is not unusual for
the chorea and the psychosis to differ in severity in the
individual case.

Course and Termination

The progressive course which characterizes the ma-
jority was once thought to be the absolute rule. We
now know that a fair number of choreics remain sta-
tionary for many years or at least progress very slowly.
However, authentic cases of recovery are almost un-
known. In other words the victims of the disease always
die with it and usually from its effects; exhaustion, sui-
cide, intercurrent infection, or cerebral vascular accidents
are common causes of death.

The duration of the fully developed syndrome varies
from one to fifty years in extreme cases. However, there
is a remarkable tendency for a large proportion of cases
to be of thirteen to sixteen years in duration regardless
of the age of onset.

Pathology

The pathology 5 is characterized by extensive nerve
cell deficiency and degeneration with proliferation of the
fibrous neuroglial elements which result in gross brain
atrophy with dilatation of the ventricles. These changes
are most marked in the cerebral cortex, especially the
frontal region, and in the corpus striatium. In the latter,
involvement is primarily in the caudate nucleus and the
putamen.

Although the above findings are generally accepted as
typical for an advanced case, there is surprisingly little
agreement as to details. One pathologist went so far as
to state that the occurrence of organic changes in the
brain is the only point upon which there is complete
agreement.

As in many other diseases of the central nervous sys-
tem the pathological findings correlate rather poorly with
the clinical findings. Cases are reported in which the
pathological findings are virtually identical but in which
the clinical picture, duration, type of onset, and severity
vary to the extreme.,1,;’,<’

The abnormal involuntary movements are believed to
be related to the structural changes in the basal ganglia
while the personality and intellective symptoms are de-
termined in part by those changes in the cortex, espe-
cially the frontal region. In both instances it appears
that the abnormal symptoms result, not so much from
the cells which are damaged, as from the "uninhibited”
action of the remaining structures.

Heredity

The inheritance of insanity has been a topic of great
interest for generations. Little progress has been made

largely because of the complexity of the problem. Among
the serious stumbling blocks is our lack of a satisfactory
scientific classification of the psychoses. However, in
Huntington’s chorea we find a condition which is rela-
tively well defined. It is easy to identify clinically since
it is clearly distinguishable from other forms of person-
ality and neurological aberration.

It is generally agreed that there is direct dominant
transmission to the child from an affected parent of
either sex.

Predictability is poorly understood beyond the facts:
(a) that each child of a choreic parent has a one to one
chance to develop the disease, (b) the ages of from 25
to 55 are those during which the disease is most likely
to show itself. As he passes the age of 55, an individual
from an afflicted family can have increasing assurance
that he is not likely to develop the disease. If he does
not develop it, he need not fear that his children will
have it.

In 1872, Huntington wrote "Unstable and whimsical
as the disease may be in other respects, in this it is firm,
it never skips a generation to again manifest itself in
another; once having yielded its claims, it never regains
them.” This is essentially true today. However, a par-
ent may die before the disease becomes manifest — but
after he has transmitted the condition to his son. Most
cases of "skipped generation” are of this type. Sporadic
cases due to mutations or "sports” are believed to be rare
but they can occur. Such cases may be transmitted to
succeeding generations. The detection of a positive fam-
ily history is often more difficult than many physicians
apparently realize. There are many reasons why the his-
tory may be falsely negative:

(1) The patient may be an illegitimate offspring of
a choreic parent. This is a fairly likely occurrence since
Huntington’s chorea is often characterized by immoral
and lascivious behavior.

(2) The parent may die before the condition develops
but after it has been transmitted to his children.

(3) For these or other reasons he may not know of
his parent’s condition.

(4) Patients and families, perhaps for shame, family
pride, or other reasons, may deny the family history.

Possible Genetic Significance of Biotypes
and Other Variations

While Huntington’s chorea as a disease has many
variations, these are not so marked among the individ-
uals within a kinship. In other words, certain families
have a unique trait or combination of traits which tend
to reappear in all the choreics of that kinship. For ex-
ample, one family may be characterized by an early age
of onset, rapid progression, and marked severity of the
symptoms. Another may be characterized by slow pro-
gression and mild personality disorders, or by the onset
of the tremors in some special location as in the case of
the family known as the "head nodders.” '

The occurrence and transmission of these various fam-
ily differences enable us to recognize sub-varieties or
biotypes.

These biotypes have been a source of considerable in-
terest to geneticists in that certain elements of the dis-

November, 1946

395

order may be inherited without the transmission of the
rest of the disease picture. Thus, it seems probable that
the separate transmission of the hereditary potentials
leading to the chorea and to the psychosis is possible.
Such variations may be the result of "hybridization of
the biotype with diluted and untrue clinical expression.”1
Certainly, any single hereditary potential can be expressed
differently in different individuals or families. s Such
considerations may give us clues as to the manner in
which hereditary potentials may appear among the etio-
logical factors in certain cases of schizophrenia, psycho-
pathic personality, and other types of personality dis-
orders.

The hereditary aspects of the functional psychosis are
poorly understood largely because of the complexity of
the problem. Certainly, we do not have a working un-
derstanding on which there is any common agreement.
Unfortunately, hereditary considerations are often either
overvaluated or largely ignored. By comparison with
many of the psychoses, Huntington’s chorea is a rela-
tively clear-cut condition concerning which there are
fairly definite rules. Even here there are other factors
of etiological significance. Although the hereditary fac-
tor appears to be of overwhelming importance, it is not
the sole predeterminer in the symptomatology of this
condition. The mental content and many of the behavior
aberrations, for example, must be related to the life ex-
periences and other environmental influences.

The belief is widespread 3,9 that choreic families also
contain a large number of non-choreic members who are
psychotic, emotionally unstable, epileptic, psychopathic,
or otherwise defective. Although this is apparently true
of many families, there are others in which there are a
large number distinguished by economic, professional,
or political attainments. Unfortunately, no good study
on non-choreics in the affected families has been made
which would settle this question. Even if a significantly
high number of deviant non-choreic individuals can be
shown to exist in these families, the psychogenic and
social aspects of the genesis of their deviations must also
be considered.

The psychogenic importance of the fear of chorea
itself must be considerable in the case of non-choreic
siblings. Likewise, psychologically traumatic situations
are frequent in a family in which a parent is afflicted
by this unfortunate disease.

Eugenic Considerations

The marriage rate and the fertility are both high.
In one sample 1(1 there were only 35 single as compared
to 218 married choreics. The average choreic family
probably has about five children.

The perversity of the human race in the face of such
dangers is well known. Many cases are cited in which
it has been impossible to dissuade normal people from
marrying potential choreics, e.g.: one farmer, whose wife
had died of the disorder, married her sister and she too
developed the disease.' In other words, even if predicta-
bility were possible, the problem would not be solved.

However, one of the first steps forward toward the
control of this disorder should be an attempt to discover
criteria which will indicate or at least give clues as to

which members of a sibship will develop the disease. As
far as is known to the author, no work has been done
on this. The periodic examination of every member of
several sibships by modern methods may well provide the
desired criteria. In addition to routine history, medical,
neurological, and psychiatric examinations, the studies
should include electroencephalography and a battery of
standardized tests. The latter might well consist of (a)
a group of general personality tests like the Minnesota
Multiphasic Personality Inventory and the Rorschach
test; (b) psychometric tests of coordination, motor con-
trol, and steadiness; (c) tests for intelligence and for
intellectual changes associated with brain damage.

It seems unlikely that effective treatment can be found
though cortical extrapation,1 1 vitamin E and fever ther-
apy are among the treatments being considered. Eugenic
control may be possible at some future date through the
combined efforts of several disciplines such as medicine,
sociology, and genetics.

Occurrence

The first cases of Huntington’s chorea are believed
to have migrated to the United States from England
in 1636. 12 At one time almost all of the choreics were
to be found in the New York-New England area though
subsequently lesser centers have been described in Michi-
gan, Iowa, and other parts of the country. There is no
real evidence that the disease is dying out as some writers
have claimed. On the contrary, it probably is slowly
increasing.

In 1916 it was possible for Davenport1’ to collect the
records on 962 choreics in this country. It is estimated
that mental institutions have one or two choreics for
every one thousand patients, and that there are about
four times that many at home. The sexes are about
equally divided, and it occurs most commonly in the
Caucasian race.

No complete data are available regarding the occurrence of
the condition in Minnesota. The mental hospitals of the state,
with a patient population of approximately 12,000, usually have
between 40 and 50 recognized cases at any one time. At present
there is no way of knowing how many non-institutionalized cases
there are in Minnesota, but it is reasonable to suppose there are
between 150 and 200. It is likely there will be many more cases
in the future. By way of illustration, one Minnesota sibship
from the Z kinship, previously reported by the author, had a
total of 36 living offspring in 1943. All of these are living in
Minnesota; and though the majority are too young as yet,
many will develop the disease.

Summary

1. The clinical features of Huntington’s chorea have been
presented with adequate emphasis on the variation and biotypes.

2. The hereditary characteristics of Huntington’s chorea make
it a promising field for the study of human genetics. The heredi-
tary transmissions of specific biotypes and of unique individual
traits suggest that further hybridization and transmutation may
result in hereditary potentials which have an important role in
the production of other personality disturbances such as the func-
tional psychoses and certain non-psychotic behavior aberrations.

3. There is no effective treatment, but prevention may be pos-
sible. An important first step in such control will be the estab-
lishment of criteria by which it will be possible to predict which
members of a sibship will develop the disease. The periodic
study of several sibships by a battery of modern tests and exam-
inations should provide the desired criteria.

Bibliography

1. Huntington, George: On Chorea. Med. and Surg

Reptr., Philadelphia, 26:317 (April), 1872.

2. Neurographs, 1:1908 (Huntington’s Chorea Number).

396

The Journal-Lancet

3. Bell, Julia: Huntington’s Chorea. Treasury of Human
Inheritance, 4:1934.

4. Falstein, E. I., and Stone, T. T.: Laboratory Studies in
Huntington’s Chorea. 111. Med. J., 77:47-49, 1940.

5. Stone, T. T., and Falstein, E. I.: The Pathology of

Huntington’s Chorea. J. of Nerv. and Ment. Dis., 88:602-
626, 773-797, 1938.

6. Wilson, S. A. K., and Bruce, A. N.: Neurology, 844-
857. Williams and Wilkins, Baltimore, 1940.

7. Davenport, Charles B., and Muncey, Elizabeth: Hunt-
ington’s Chorea in Relation to Heredity and Eugenics. Am. J.
of Insan., 23:195-222, 1916.

8. Oliver, C. P.: Personal communication.

9. Hughes, Estella M.: The Social Signs of Huntington’s
Chorea. Am. J. of Psychiat., 4:536-574, 1923.

10. Popenoe, Paul, and Brousseau, Kate: Huntington’s

Chorea. J. of Heredity, 21:113-118 (March), 1930.

11. Kepner, R. D., and Cloward, R. B.: Psychosis with

Huntington’s Chorea. Dis. Nerv. Sys., 3:326, 1942.

12. Vessie, P. R.: On the Transmission of Huntington’s

Chorea for 300 Years. J. of Nerv. and Ment. Dis., 76:553-
573, 1932.

13. Oliver, C. P., and Schiele, B. C.: A Family History of
Huntington’s Chorea Made Possible by the Recording of Sur-
names. The Dight Institute Bulletin, No. 3, 1945, Univ. of
Minn. Press, Minneapolis.

. . . fUEET OUR COEITRIBUTORS . . .

Dr. Donald Hastings, guest editor, is professor and head
of the department of Psychiatry and Neurology, University of
Minnesota, Minneapolis. Prior to his release from the Army,
he was Chief Psychiatrist in the AAF. He was graduated from
the University of Wisconsin in 1934, with B.A., M.A., and
M.D. degrees. He was a Fellow in Psychiatry of the Rocke-
feller Foundation at the Pennsylvania Hospital for Nervous and
Mental Diseases, Philadelphia, 1936-37, and at the Institute of
Pennsylvania Hospital, 1937-38. He is a member of the Hen-
nepin County Medical Society, Philadelphia County Medical
Society, Philadelphia Psychiatric Society, and the American
Psychiatric Association.

Dr. J. Arthur Myers is a well-known Minneapolis physi-
cian, and since 1914 has been on the staff of the Medical School
of the University of Minnesota.

Dr. Edward A. Strecker, Philadelphia, has been practicing
psychiatry for 25 years. He is a graduate of Jefferson Medical
College, class of 1911, with degrees of A.B., A M., M.D.,
Sc.D., Litt.D., LL.D. A few of his many activities in the field
of psychiatry are as follows: former president of the American
Psychiatric Association, former vice-president of the American
Neurological Association, and one of the Thomas William
Salmon lecturers. At present he is on the Commission of Six
to administer the $12,000,000 U.S.P.H.S. Bill for psychiatry
and mental hygiene, a fellow of the American College of Physi-
cians, and a member of the A M. A., American Psychiatric As-
sociation, and the American Neurological Association.

Dr. Hans H. Reese has been professor of neurology and
psychiatry at the University of Wisconsin, Madison, since 1924.
He is a graduate of the University of Kiel, Germany, and did
graduate work at the University of Hamburg. He is a mem-
ber of the A M. A., American Neurological Association, Col-
lege of Psychiatry, American Psychiatric Association, and the
Wisconsin Medical Society. He was past president, and is now
a member of the American Board of Neurology and Psychiatry,
and the Office of Scientific Research, War Department.

Dr. Bernard J. Alpers is professor of neurology, Jefferson
Medical College, Philadelphia. He received his M.D. from
Harvard University in 1923 and did graduate work at the
University of Pennsylvania, 1926-29, Sc.D. (med.). He has
practiced in Philadelphia for 16 years, and is a member of the
A M. A., American Neurological Association, and the American
Psychiatric Association.

Dr. Roy Grinker is chief of the Psychiatric Service, Michael
Reese hospital, Chicago. During the war he was awarded the
Legion of Merit for his services as neuropsychiatrist on the staff
of the Air Surgeon, Northwest African Air Forces. On return-
ing to this country he was made Director of Professional Serv-
ices and Psychiatry of the Don Ce-Sar Convalescent Hospital,
St. Petersburg, Florida. He is co-author with J. P. Spiegel of
Men Under Stress (Blakiston), one of the best books on psy-
chiatry to come out of the war.

Dr. Henry W. Woltman has been associated with the
Mayo Clinic since 1917 and his specialty is neurology. He is a
graduate of the University of Minnesota, class of 1913, with
B.S., M.D., and Ph D. degrees. He did graduate work in
neuropsychiatry at the University of Minnesota. He is a mem-

ber of the A.M.A., American Neurological Society, American
Psychiatric Association, Central Society for Clinical Research,
Research Society in Nervous and Mental Diseases, Society of
Biological Psychiatry, and the Minnesota Society of Neurology
and Psychiatry.

Dr. Alfred W. Adson has been with the Mayo Clinic since
1917. His specialty is neurologic surgery. He received his M.D.
degree from the University of Pennsylvania in 1914, and also
has B.S., M.A. and M S. (surgery) degrees, with graduate work
at the University of Minnesota. He is a member of the
A M. A., Minnesota State Medical Association, American Col-
lege of Surgeons, Society of Neurological Surgeons, and the
American Neurological Association.

Dr. Kenneth H. Abbott is at present a Fellow in neuro-
surgery at the Mayo Foundation, Rochester. He received his
M.D. from the College of Medical Evangelists, Loma-Linda,
Los Angeles, California. He was a Captain in the AUS from
1943-45.

Dr. Douglas D. Bond is professor of psychiatry, Western
Reserve University Medical School, Cleveland, Ohio. He was
graduated from the University of Pennsylvania Medical School
in 1938, M.D. degree. He was a teaching Fellow in Physiology
at Harvard Medical School from 1941-42. During the war he
was active in the field of psychiatry in the 8th Air Force. He is
a member of the A M. A., Ohio State Medical Society, and the
American Psychiatric Association.

Dr. Abe B. Baker, Minneapolis, has been associated with
the University of Minnesota medical school for 15 years, and
specializes in neurology and neuropathology. He was graduated
from this university in 1930 and holds the following degrees:
B.A., B.S., M.D., M.S., and Ph.D. He is a member of the
American Neurological Association, American Association of
Neuropathologists, Central Neuropsychiatric Association, Min-
nesota Society of Neurology and Psychiatry, and is a Fellow in
the A. M.A.

Dr. David Daly, who was graduated from the University of
Minnesota in 1945, B.A., B.S., and M.D., now has a Fellow-
ship at this university, and is specializing in neurology.

Dr. John E. Skogland, Houston, Texas, is on the faculty of
Baylor University College of Medicine. He was graduated from
the University of Minnesota, M.B., 1935, M.D., 1937, M S.
(neuropsychiatry), 1937, Ph.D. (neuropsychiatry), 1940. He
also did graduate work at Harvard University, 1940-41. He is
a member of the Texas Neuropsychiatric Society.

Dr. Lawrence R. Gowan has been a neuropsychiatrist in
Duluth, Minnesota, for 21 years. In 1922 he was graduated
from the University of Minnesota, B.A., M.D., and M.S.
(neuropsychiatry). At the time of his release from the USNR
in July, 1945, he was Captain in the medical corps. He is a
member of the Minnesota Society of Neurology and Psychiatry,
Central Neuropsychiatric Association, and the American Psy-
chiatric Association.

Dr. Burtrum C. Schiele is an associate professor of psy-
chiatry at the University of Minnesota, and has been associated
with the University of Minnesota Hospitals since 1937. He is
a graduate of the Colorado University Medical School, class
of 1931, A.B. and M.D., with graduate work at this university
and at Cornell. He is a member of the Hennepin County Med-
ical Society, American Psychiatric Association, Central Neuro-
psychiatric Association, and the Minnesota Neurologic and Psy-
chiatric Association.

i North Dakota State Medical Assn. South

Dr. A. E. Spear, Pres. Dr.

Dr. Philip G. Arzt, Pres.-Elect Dr.

Dr. L. W. Larson, Secy. Dr.

Dr. W. W. Wood, Treas. Dr.

North Dakota Society of South

Obstetrics and Gynecology Dr.

Dr. Paul Freise, Pres. Dr.

Dr. G. Wilson Hunter, Vice Pres. Dr.

Dr. F. A. DeCesare, Secy. -Treas. c-

cnoux

Minneapolis Academy of Medicine Dr.

Dr. Russell W. Morse, Pres. Dr.

Dr. Paul F. Dwan, Vice Pres. Dr.

Dr. J. C. Miller, Secy. Dr.

Dr. Ragnvald S. Ylvisaker, T reas.

Dr. Henry E. Hoffert, Recorder

Dr. J. O. Arnson
Dr. A. B. Baker
Dr. D. S. Baughman
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W A. Fansler

Dr. A. R. Foss
Dr. J ames M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. L. W Larson
Dr. W. H. Long
Dr. O. J. Mabee

ADVISORY COUNCIL

Dakota State Medical Assn.

F. S. Howe, Pres.

H. R. Brown, Pres.-Elect
J. L. Calene, Vice Pres.
Roland G. Mayer, Secy.-T reas.

Dakota Public Health Assn.

J. M. Butler, Pres.

C. E. Sherwood, Vice Pres.
Gilbert Cottam, Secy. -Treas.

Valley Medical Assn.

D. S. Baughman, Pres.

Will Donahoe, Vice Pres.

R. H. McBride, Secy.

Frank Winkler, Treas.

Montana State Medical Assn.

Dr. M. A. Shillington, Pres.

Dr. L. W. Allard, Pres.-Elect
Dr. H. T. Caraway, Secy.-T reas.
Northwestern Pediatric Society
Dr. G. B. Logan, Pres.

Dr. Geo. Kimmel, Vice Pres.

Dr. Northrop Beach, Secy .-Treas.
Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.

Dr. R. C. Webb, Secy. -Treas.
American Student Health Assn.

Dr. Ralph I. Canuteson, Pres.

Dr. Laurence Chenoweth, Vice Pres.
Dr. G. T. Blydenburgh, Secy .-Treas.

BOARD OF EDITORS

Dr. J. A. Myers, Chairman
Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C. H. Nelson
Dr. N. J . Nessa
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. C. E. Sherwood

Dr. M. A. Shillington
Dr. J. C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J. H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. S. E. Sweitzer

Dr. W. H. Thompson
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N Wynne
Dr. Thomas Ziskin,
Secretary

LANCET PUBLISHING CO., Publishers, 84 South Tenth St., Minneapolis 2, Minnesota
Minneapolis, Minnesota, November, 1946

NORTH CENTRAL STATES SOCIO-MEDIC
PROBLEMS

It must be conceded that there is a persistent demand
for a prepayment medical and hospital care-plan-provi-
sion by and for the public. This fact was recognized by
the A.M.A. when at its last meeting it took the unprece-
dented step of instructing its committee on public rela-
tions and medical service to develop a national prepay-
ment health program. This committee was also instructed
to coordinate all existing plans and to stimulate the for-
mation of new ones in areas where none exist at present.
The Minnesota State Medical Association approved a
prepayment medical-care-plan at its last meeting. Com-
mercial companies writing insurance in the state of Wis-
consin have agreed to write a standard policy approved
by their association as to premium provisions and bene-
fits, and this has become known as "The Wisconsin
Plan.” The committee on prepayment and insurance
plans of the South Dakota State Medical Association
deplored the fact that the necessary enabling act failed
' to pass the last session of the state legislature and under
i the circumstances expressed the feeling that for the pres-

ent their needs could best be served by a program similar
to that in Wisconsin.

North Dakota has evidenced increasing interest in a
prepayment plan. A request was submitted to Senator
Murray, chairman of the committee on education and
labor, for an opportunity to appear before the committee
at a hearing on the Murray-Wagner-Dingell bill, but
permission was denied. Dr. Hanna, in his presidential
address at Bismarck, cited three important problems con-
fronting the medical profession, which are: equitable dis-
tribution of physicians, of medical facilities, and of med-
ical costs. The Cass County Medical Society already has
a prepayment medical plan in conjunction with the Blue
Cross group and any district medical society in North
Dakota may join and participate in this venture. Mon-
tana was first denied, but later accorded, an invitation
to appear before the committee hearing views on senate
bill No. 1606. It was the impression of Dr. Cooney,
president of the Montana State Medical Association,
based upon the questions of Senator Donnell, that state
organizations were much more representative of the pro-
fession than national organizations, which is quite un-
derstandable. A. E. H.

397

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The Journal-Lancet

THE FUTURE OF PSYCHIATRY

Medicine, as do other professions, tends to travel in
waves, each rising school of thought or theory holding
sway for a shorter or longer period depending upon its
fundamental soundness and usefulness, then falling away
to be lost, or remaining as a part of the body of knowl-
edge which constitutes either the science or practice of
medicine. One of the fundamental pieces of the pro-
fessional equipment of the physician always has been
his relation to his patient. Since the turn of the century
and with the introduction of precision instruments and
scientific methodology into medical practice, the funda-
mental relation of the doctor and patient tended to be
lost or forgotten. The doctor by virtue of his training
came to look at his patient as a mass of pieces and parts,
some of which had become fouled, and which required
fixing if the symptoms were to be done away with. The
patient thus came to be regarded as a 'rheumatic heart
or an "acute appendix” hut the fact that the patient was
also a person, with the feelings of a person, often was
overlooked. One of the most powerful agents in the
physician’s professional bag thus was discarded. Here
and there various doctors intuitively discovered and used
this old truth, but only two groups really practiced it
throughout these past 50 years. One group was that of
the general physicians whose daily contact with the pa-
tient and his family produced real regard of the patient
as a person. The other group was that of the psychia-
trists, who possessed few other therapeutic tools beyond
that of the doctor-patient relationship with its intricate
workings.

In the past few years, physicians generally are again
returning to see the value of the examination of the
patient as a person, and to recognize once again that
the doctor-patient relationship may often have more
therapeutic meaning than any or all medications. There
are many reasons for this changing viewpoint. World
War II exposed most of the younger physicians to the
inescapable fact that many a sick soldier, without phys-
ical findings to explain the difficulty, was a sick person
in the ordinary sense of the word; the war experiences
also demonstrated to thousands of physicians (and not
infrequently demonstrated it to the doctor in a very
personal intimate manner) that emotional conflict and
stress could produce physical symptoms of anxiety which
were just as crippling as a gunshot wound. The war
also demonstrated to the country as a whole the appalling
numbers of American youth who were not fit to fight
for their country because they were not sound mental
or emotional specimens. The war also disclosed that
many (40 per cent) of the soldiers and sailors who had
to be discharged for medical disability, were discharged
labelled with neuro-psychiatric diagnoses. Then, too, the
mental hygiene movement and the teachings of the dy-
namic school of psychiatry had gradually filtered through
all levels of medical practice. All physicians had noted

that many of their patients had physical complaints
which they could not explain by the physical findings.
It is reliably estimated that approximately one third of
all the patients who consult doctors have no organic rea-
sons for their complaints. Obviously then this group of
patients, if they are to be handled by medical men, must
receive treatment directed at something other than phys-
ical disease. Also it had become apparent that patients
with actual organic disease might have psychological
components which contributed either to the illness or to
the problem of convalescence. Thus many factors have
led to a recent awareness that emotional stress and con-
flict can produce illness.

What then are the general trends of psychiatry today
and what seems to be the future of psychiatry? First
of all, at the medical school level, the main trend is to
devote the majority of the allotted teaching hours to
psychoneuroses in general and to psychosomatic problems
in particular. The old idea of exposing the medical stu-
dent to the gross disorders of thinking and behavior
(the psychoses or insanities) has now been almost com-
pletely dropped since it gives the student a perverted
idea of the emotional problems of people and because he
will never have much use for the knowledge in the gen-
eral practice of medicine. The next few years will prob-
ably see the majority of medical schools teaching psy-
chiatry to their students entirely in the medical out-
patient department, instructing them in the handling of
the patient as a whole.

By the same token of teaching the medical student
the fundamentals of treating psychosomatic problems,
the future of psychiatric practice will come to lie in the
hands of the general practitioner and also of the internist
to a somewhat lesser degree. With adequate medical
school instruction, the average physician can handle 80
per cent or more of his psychosomatic and psychoneur-
otic patients. The formally trained psychiatrist will prob-
ably come to find his place as a teacher, as a researcher,
and as a clinician who handles psychiatric problems
which are beyond the scope of the general practitioner.

In general, then, psychiatry will demonstrate its grow-
ing maturity as a specialty by uniting itself firmly with
the other clinical specialties and also with the basic
sciences. Psychiatry will, in particular, come to have its
fullest maturity by teaming with internal medicine. Psy-
chiatry will gain much by this wedding. It will become
more mindful of the scientific method and the evalua-
tion of techniques and results. It will borrow the method
of other disciplines to determine if they may apply
toward the exploration of the psychiatric vastnesses
which presently are largely uncharted. To the other
specialties with which it allies itself, psychiatry will bring
the oldest and the newest concept in medicine; the re-
gard of the patient as a person; the regard of the person
as a whole being.

Donald W. Hastings, M.D.

fP^n^ic/iavi £Rcc/ie for the relief of smooth muscle spasm

^^yntropan has the desirable, antispasmodic actions
of belladonna or atropine, but does not depress salivary secretion as actively nor
induce mydriasis as readily. When used to induce mydriasis, its influence is not as
profound nor as long in duration as that of atropine. The inhibitory action of
Syntropan on the parasympathetic innervation of the heart is negligible and not
as pronounced as that of atropine. Syntropan has a definite antispasmodic action on
spastic smooth muscle, the antispasmodic influence being due jointly to inhibition of
the parasympathetic innervation and to direct peripheral relaxing action on the muscle
Fibers themselves . . . HOFFMANN-LA ROCHE, INC., NUTLEY 10, NEW JERSEY

AdveAtUtbs' AhHOUHC€*ftChU

UPJOHN EMPLOYS FINE ART

"The Upjohn Company, which manufactures medical supplies
at Kalamazoo, Michigan, has long made stimulating use of
graphic art in its house organ, Scope, and in other publicity
material.

Painting by Bernard Karfiol used to illustrate the Up-
john Company’s health message: " And they thought she
would always be paralyzed.” Photo courtesy Midtown
Galleries, New York.

In 1944, at the suggestion of the William Douglas McAdams
advertising agency, it adopted paintings to illustrate a series of
advertisements "Your Doctor Speaks.” The company decides
on the desired themes, then employs the Midtown Galleries,
New York, to search exhibitions and studios for existing paint-
ings suitable for use as illustrations. Selections to date include
works by Waldo Pierce, Fletcher Martin, Bernard Karfiol and

other artists. Ten of the advertisements bearing color reproduc-
tions of paintings have been bound in portfolio form and dis-
tributed to 100,000 doctors for use in their waiting rooms. The
original paintings organized into the Upjohn collection are now
on tour.*

The Upjohn procedure of purchasing existing paintings re-
lieves the artist of all commercial pressure in creation of his
work. Some of the examples selected, one of which is shown,
are representative of better American paintings today. The
pathological context results from using the paintings as illus-
trations to medical themes. A Fletcher Martin portrait is accom-
panied by the caption "Anemia?” The Karfiol figure-study
shown was published under the caption, "And they thought
she would always be paralyzed.”!

An interplay between art and other activities of society makes
for mutually beneficial integration, — -something that has been
sadly lacking in recent times. The Karfiol figure-study has
been reproduced in color by the Upjohn Company in magazines
having a combined circulation of 9,377,000. Eighteen additional
paintings have been or will be reproduced in the series. The
total number of reproductions of the paintings to appear in
magazine advertisements is 100,242,000. In addition the Up-
john reprint portfolio, 100,000 copies, ten reproductions in
each copy, makes another million color prints. Thus, this one
company in this one advertising campaign is circulating well
over 100,000,000 free color reproductions.” — From the Maga-
zine of Art, March, 1946.

Parke-Davis Constructing New Antibiotic Laboratories

Construction of a new antibiotic laboratory has been started
by Parke, Davis & Company in Detroit. The three-story build-
ing will be 496 feet long by 90 feet wide, with provision being
made for the addition of a fourth floor when necessary. Erec-
tion of the building is expected to be completed in record time.

Special machinery designed by Parke-Davis engineers will be
installed in the building. Processing equipment will be of special
alloy type or glass-lined construction, and approximately 3500
horsepower in electrical apparatus will be required to drive air
compressors, fermenter agitators, and refrigeration machinery.

The new laboratories will be devoted to research development
and manufacture in the vast field of antibiotics, which includes
such drugs as streptomycin and penicillin.

ESTINYL COUNCIL ACCEPTED

Estinyl, Schering’s ethinyl estradiol, the most potent oral
estrogen known today, has been accepted by the A.M.A. Coun-
cil on Pharmacy and Chemistry. Estinyl is marketed by Schering
Corporation of Bloomfield and Union, New Jersey, manufac-
turers of endocrine and other important pharmaceuticals for the
medical profession. With dosages being measured in hundredths
of a milligram, this uniform potency results in economy to the
patient. Estinyl has been proven of great value clinically in
estrogenic deficiencies in the female, as in post-menopausal
states. It is also used in the male to palliate the symptoms of
metastatic prostatic carcinoma. Estinyl is supplied in tablet
form, in 0.05 mg. or 0.02 mg. strengths, in bottles of 100,
250, and 1,000 tablets.

•Mentioned in this column of the April issue.

tA full page advertisement in a mid-September issue of LIFE
carries the heading, "New hope for childless couples.” This is
illustrated by another painting by Karfiol, figures of a man and a
woman. It is the sixteenth of a series.

WHERE ELSE CAN YOU
GET ALL THIS

But at

DENSON LABORATORIES?

PRESCRIPTION ANALYSIS OPHTHALMIC DISPENSING

LENS GRINDING LENS TEMPERING

CONTACT LENSES
ORKON LENSES (Corrected Curve)

COSMET EDGES (Distinctive style and beauty)

HardRx LENSES (Toughened to resist breakage )

SOFT-LITE LENSES (Neutral Light Absorption, the 4th Prescription Component)

N. P. BENSON OPTICAL COMPANY

Established 1913

MAIN OFFICE: MINNEAPOLIS, MINNESOTA

Aberdeen - Albert Lea - Beloit - Bismarck - Brainerd - Duluth - Eau Claire
Huron - La Crosse - Rapid City - Rochester - Stevens Point - Wausau - Winona

Plasma Proteins in Surgery:

A Review of the Literature

R. O. Quello, M.D.

Minneapolis, Minnesota

Slightly over 100 years ago a Dutch chemist named
Mulder recognized a large group of important sub-
stances having similar general characteristics. These sub-
stances he called proteins, from the Greek word "pro-
teios” meaning first or pre-eminent, since they seemed
to be of such fundamental importance in body and plant
function. The chemistry of proteins may be considered
as starting when a French scientist named Braconnot
prepared the amino acid glycine from gelatine in an
attempt to determine whether acid decomposition of a
protein behaved like starches, with the resultant, forma-
tion of sugar.

These early studies, however, were on protein materials
containing many other substances besides proteins, and
it was not until about 1850 that a German investigator
named Ritthausen was able to isolate plant proteins in
relatively homogenous form. Thus a new field in chem-
istry was opened and many investigators, using the meth-
od of acid or alkaline hydrolysis, isolated the substances
we now know as amino acids. However, all of these studies
were studies in chemistry with no attempt at clinical
application until about 1907, when an American bio-
chemist, T. B. Osborne, explained that the various pro-
teins had different nutritional values. He began break-
ing down protein molecules and comparing their con-
stituent amino acids, with the conclusion that the differ-
ence in nutritional value was due to the difference in
component amino acids. This prompted the study of
comparing the various proteins as they affected the
growth of experimental animals. Together with Men-
dell of Yale, Osborne noted that certain amino acids
could be synthesized within the animal body, that other

Presented before the meeting of the staff of Swedish Hos-
pital, Minneapolis, Minnesota, October 14, 1946.

amino acids could not and had to be supplied in food.
Those amino acids necessary for growth but unable to
be synthesized within the body they termed "essential”
amino acids.

At about this time came the discovery of vitamins,
causing sufficient excitement to nearly shelve further pro-
tein research, and it was not until 1935 with the work
of W. C. Rose of Illinois, that all amino acids "essential”
for growth of the rat were named. Cautious extension
of experimental application to man is in progress, and
would indicate the amino acid requirements of man are
probably the same. This measure of human requirements
has followed in a study of nitrogen balance, in which the
quantity of excreted nitrogen is compared with that in-
gested by varying food mixtures. Normally, intake and
output are about the same. An increase in nitrogen ex-
cretion above the calculated required intake would indi-
cate an inadequate food mixture for body tissue main-
tenance. Accepting the probability of the amino acids
"essential” for certain experimental animals as being also
' essential” for man, these are: arginine, histidine, lysine,
tryptophane, phenylalanine, methionine, threonine, leu-
cine, isoleucine, and valine.

Proteins in their natural form are large complex mole-
cules. All contain carbon, hydrogen, nitrogen and oxy-
gen, most contain sulfur and some contain phosphorus.
Other elements found are iron, iodine, copper, manga-
nese, and zinc. Molecular weights are enormous and
range from 900 for graminic acid to 8,500,000,000 for
psittacosis virus. The molecular weight of serum albumin
is 70,000 and serum globulin 165,000.

Proteins are classified on the basis of physical prop-
erties, chiefly solubility, and not on chemical behavior
because of the complexity of the molecule. They fall

399

400

The Journal-Lancet

into two main groups: (1) Simple proteins, those which
on complete hydrolysis yield alpha amino acids. Exam-
ples of this group are albumins and globulins. (2) Con-
jugated proteins, or compounds of a protein with an-
other molecule. Examples are nucleo proteins and phos-
phoproteins.

The chemical structure of proteins show they are com-
pounds of many amino acids joined in peptide linkage,
which is defined as the union of a carboxyl group to an
amino group with the elimination of a molecule of water.
Two amino acids so linked form a dipeptide, add a third
and form a tripeptide. Further additions form a poly-
peptide, and so on to the formation of proteoses, then
peptones and finally the complex protein molecule itself.
In protein digestion within the intestinal tract, practically
the reverse procedure occurs. The ingested large protein
molecule through hydrolytic cleavage by enzymes secret-
ed within the alimentary canal is broken down ultimately
into their constituent amino acids. These are absorbed
from the small intestine into the portal blood. It is at
this point that the clinical significance of "forced” pro-
tein therapy enters into the picture because commercially
prepared proteins are products at this stage of digestion.
Given orally they are ready for absorption, or given par-
enterally they side-step absorption, either way permitting
forced protein feeding in quantity above that possible
in high protein diets.

These recent advances are partially the result of war
research. In the early stages of the war, the demand for
plasma by the armed forces was greater than the avail-
able shipping space. This need precipitated the use of
the plasma protein fraction, serum albumin, in combat-
ing shock. Later, in the treatment of the debilitated in-
habitants of concentration camps, the value of concen-
trated protein hydrolysates was overwhelmingly demon-
strated.

Returning now to the fate of the amino acids or end
product of protein digestion; these are absorbed prac-
tically unchanged from the intestine into the blood
stream. From here they may be removed by all tissues
of the body, accumulating in the cellular and extracellu-
lar fluids. From this temporary storage, tissue cells may
remove certain of the acids as needed for the growth of
new tissue. Twenty-five amino acids are now recognized
from plant and animal proteins of which twenty-two
have been identified as nutritionally important and ten
as "essential”.

Amino acids reaching the liver are somehow assorted,
a part of them are re-manufactured to help build serum
proteins. Amino acids not required for tissue building or
repairs are deaminated or broken down by the liver with
the formation of carbohydrate and non-protein nitrogen,
the latter excreted chiefly in the urine. It is estimated
that approximately one half of the deaminized amino
acid molecules are converted to carbohydrate. This con-
version to carbohydrate is increased at the expense of
tissue building in the presence of a shortage of energy
food. For this reason, for any condition where increased
protein therapy is indicated general caloric intake should
be increased simultaneously so that protein designed for
may be utilized to maintain an adequate protein level.

Following the work of Sherman at Columbia University,
approximately one gram of protein per kilogram of body
weight is indicated as optimum intake for the normal
adult, with increases to half again to twice as much in
pregnancy, lactation, growth, and even more if indicated
in certain pathological conditions.

In this paper we are concerned primarily with plasma
proteins. These are of at least two distinct varieties; the
albumins and globulins, with the latter further fraction-
ated into fibrinogen, alpha, beta, and gamma globulins.
Normal levels of serum proteins and the fractions albu-
min, globulin and fibrinogen expressed as per cent of
plasma are: Serum proteins, 6. 5-8. 5 per cent; albumins,
4. 0-5.0 per cent; globulins, 1.5-2. 5 per cent; fibrinogen,
0.25-0.3 per cent.

The ratio of albumin to globulin in normal human
plasma varies from 1.5:1 to 2.5:1, which ratio may vary
in different pathological conditions, hence worthy of
determination. Each of the fractions cited above have
specific physiological functions, as for example, prothrom-
bin is found in beta globulin and the circulating anti-
bodies are found in gamma globulin. Far more com-
ponents than the above fractions have been concentrated
for clinical use. As an example of this may be cited the
plasma fractionation of Red Cross blood for the armed
forces. These include: (1) Normal human serum albu-
min for the treatment of shock and in burns; (2) Im-
mune serum globulins for use in measles prophylaxis and
modification; (3) Isohemagglutinins for use in blood
grouping; (4) Thrombin used with fibrinogen for the
formation of clots in certain surgical conditions including
skin grafting and coagulum pyelolithotomy; (5) Fibrin
films, thus far used as a covering for burns and more
recently as a dura substitute in neurosurgery.

Up to this point we have discussed proteins generally
for a better understanding of their clinical significance.
Their application to surgery can probably best be re-
viewed by a discussion of a few individual conditions.

G astro-intestinal tract. In surgery involving the gastro-
intestinal tract, the provision of sufficient protein to main-
tain nitrogen balance is a definite must. These patients
frequently present themselves for surgery with a marked
hypoproteinemia and advance tissue protein depletion,
due to a combination of inadequate protein intake and
impaired digestion or absorption. Ulcers and gallbladder
disease interfere with intake, while duodenal ulcers, re-
gional ileitis, colitis, intestinal obstruction, malignancy,
and associated febrile conditions interfere with absorp-
tion. Where possible, pre-operative forced protein feed-
ings for the purpose of providing adequate storage is a
valuable adjunct.

Surgical Shock . The condition, surgical shock, and
the accompanying physiological changes responsible for
circulatory deficiency and its subsequent clinical manifes-
tations are due to the existence of a fall in blood flow.
The therapeutic problem is then one of restoring the
circulating volume before the onset of tissue damage.
The actual restoration of circulating volume, is compara-
tively simple, merely the injection of saline or glucose
solution. In non-severe cases this therapy is adequate,
but in severe cases they have proven only transitory,

December, 1946

401

and alone, are deleterious in that they possess no colloid
osmotic pressure, diffuse through the capillary membrane,
carrying more plasma with them. As far back as 1918
Drs. Rous and Wilson showed that surgical shock fol-
lowing hemorrhage was due to loss of plasma, and not
due to loss of red cell component. This same fact has
been shown since by Whipple and his co-workers in pro-
ducing hypoproteinemia by plasmaphoresis. In severe
experimental hemorrhage, studies of the plasma protein
have shown hypoproteinemia is spontaneously corrected
but the process takes days, and too often hours are im-
portant.

Present-day information has shown conclusively that
protein physiology is somehow disturbed following in-
jury. This was first emphasized in 1936 by Cutherbert-
son when he demonstrated that negative nitrogen balance
develops following fractures. In 1940, Elman of St.
Louis reported that urinary nitrogen losses occurred after
operation in spite of intravenous glucose therapy. Mul-
holland and Co Tui have demonstrated similar results
and stated that "heavy nitrogen losses were part and
parcel of every surgical intervention.” Where surgical
shock is a potential danger, the surgeon should be plasma
protein conscious. Prophylactic use of plasma may pre-
vent shock, certainly where clinical evidence of impend-
ing shock is noted, plasma, not saline or glucose alone,
should be given and in sufficient quantity. At this point
also we should not lose sight of the use of whole blood,
particularly where through hemorrhage, the replacement
of red cell component is indicated. As mentioned earlier,
the use of the plasma fraction albumin is proving its
value in combating shock. Reports from several investi-
gators show comparable results and may be summarized
by the following points enumerated by Cournand and
his co-workers at Bellevue Hospital. In this group 12
clinical cases of traumatic injury in varying degrees of
shock were given repeated injections of 25 grams of
human albumin in 100 cc. fluid.

1. In patients who were not actively bleeding or los-
ing plasma into burned tissues or peritoneum, the albu-
min was well retained. In nine cases an average of 62
grams of albumin was given and an average of 43 grams
retained.

2. Albumin therapy was effective in producing recov-
ery from shock. It increased right auricular pressure,
arterial pressure, and cardiac output.

3. Compared with treatment by whole blood transfu-
sion, albumin therapy brought about a relatively larger
cardiac output during recovery from shock.

4. The presence of acute anemia in many cases, after
albumin therapy, suggests that whole blood should be
given subsequently.

Burns. Though extensive body burns tend toward sur-
gical shock, and probably should have been discussed
with that condition, the profound effect on plasma pro-
teins makes it worthy of consideration as an individual
condition.

Following extensive burns, there is a sudden and dra-
matic increase in urinary nitrogen excretion. This in-
crease is due to excessive protein destruction. Taylor and
co-workers, in studying 22 cases of severe burns, noted

urinary nitrogen excretion as high as 45 grams in twenty-
four hours, which is equivalent to 280 grams of protein
per day. Hirschfield of Wayne University Medical Col-
lege makes the statement that patients, moderately to
severely burned, excrete more nitrogen in the urine than
can be administered orally without forced feedings.

A second source of protein depletion is protein loss
in the exudate. Again from the work of Hirschfield,
vesicle fluid from burns contains 3-4 grams of protein
per 100 cc. This protein loss begins coincidental with
vesicle formation, and continues to escape until epitheli-
alization has occurred, this latter an argument for early
skin grafting.

A third loss of protein comes in increased capillary
permeability, with escape of fluid into the tissues. With
the escape of fluid in the above mention manner, ex-
amination of the blood presents a picture of hemocon-
centration. This can become confusing in that a hemo-
concentration may result in a higher plasma protein de-
termination than actually exists. For this reason hemato-
crit readings should also be taken. Normal hematocrit
readings are: Males, 42—50 per cent cells; females, 39-43
per cent cells. A high hematocrit value with the subse-
quent correct interpretation of the misleading high blood
protein figure will often show an actual low protein level.

Edema. The blood plasma protein exerts an osmotic
pressure in the blood of 23 to 28 mm. of mercury.
Serum albumin accounts for about four-fifths of this
total, serum globulin exerting a pressure of approximately
3 mm. of mercury becomes a near negligible factor in
edema formation. With a low plasma protein level,
osmotic pressure goes down, decreasing the force that
absorbs fluid back into the circulatory system from the
tissue spaces. As a result more and more fluid accumu-
lates in the tissues and eventually edema results. Some
investigators have attempted to show quantitatively at
what albumin level edema will follow. Printed reports
show that level as 3 per cent, below which edema usually
occurs. It is now generally agreed that because of the
frequent presence of such altering factors as anemia in
which edema will often occur at higher levels, no defi-
nite level becomes critical for the appearance of edema.
It should be emphasized at this point, however, that be-
fore edema becomes perceptible generally, localized
edema at the site of operation may be enough to disrupt
healing. Dr. G. Scotchard and his co-workers at Massa-
chusetts Institute of Technology showed the volume of
fluid held in the blood stream by each gram of albumin
should be about 18 cc. but will vary with the protein
concentration of the plasma. They show further that
each gram of albumin is equivalent to 1.2 grams of
plasma protein or 20 cc. of the current Red Cross
citrated pooled plasma.

Malnutrition. This condition concerns more frequently
the aged. Loss of appetite is a common symptom of
many conditions. Lack of teeth discourages proper eat-
ing. Conditions of the gastro-intestinal tract such as
achlorhydria and chronic constipation lead to anorexia.
Diseases of the gastro-intestinal tract which interfere
with absorption are a forerunner of malnutrition. Chronic
liver disease may interfere with plasma protein synthesis,

402

and gradual breakdown of protein stores by an elevated
basal metabolic rate, febrile states and the like all lead
to varying degrees of malnutrition. The degree of hypo-
proteinemia in these cases, even in the less perceptibly
malnourished, would be interesting, perhaps startling, if
determinations were available on all hospital admissions
in this group.

Time does not permit the consideration of all surgical
aspects of protein deficiency. Yet to be considered is
their role in anesthesia, in wound healing, in infection,
injuries and many other such conditions. While the lit-
erature presents a wealth of material, there is much yet
dependent on further research.

In postoperative management, Co Tui presents some
interesting observations in a series of patients undergoing
gastrectomy. He points out the following:

1. In a series, where postoperative management was
under the classical ward regime, there was a consistent
nitrogen deficit and loss of weight, also a prolonged stay
in bed. Postoperative asthenia was demonstrated ob-
jectively which had not disappeared by the twelfth day.

2. In a series managed on high caloric and high amino
acid mixtures, there was a consistent nitrogen surplus,
a steady gain in weight, and a stay in bed of less than
one half the time required in the series managed under
the previous regime. Postoperative asthenia was consid-
erably less marked.

3. The principal source of nitrogen loss in convales-
cence following gastrectomy was the starvation postopera-
tive regimen.

4. Nitrogen loss resulting from gastric suction was
considerable.

Several methods of replacement therapy are available.
In the first place high protein diets together with high
caloric and high vitamin intake as a preoperative measure
is indicated. Where forced feeding is indicated or re-
placement therapy is desired several alternate methods
of administration are available. Oral administration of
commercially prepared amino acids such as Amigen* or
Lactaminf can be given in addition to a regular high
protein diet. These preparations are enzyme hydrolysates
of casein and lact albumin respectively. In operations
performed for ulcers, cancer, and other gastro-intestinal
conditions, feeding of these hydrolysates by tube may be
the logical procedure. Amigen has been prepared for
the intravenous route, giving as high as 50 grams in
1000 cc. of glucose solution if desired. If given intra-
venously the injection should be slow. Rapid administra-
tion frequently is accompanied by nausea and vomiting.

Individual amino acid concentrates have been prepared
and can be given where indicated, but these are still ex-
pensive and their use is still relegated to the future.

Human plasma is an excellent source of protein, and
should be used in quantity when indicated. The advan-
tage of the hydrolysates here however lies in the greater
quantity of amino acids and also the replacement therapy
for tissue proteins. Serum albumin should again be men-
tioned as a source of replacement therapy in treating
shock or an effective means of raising blood volume.

^Product of Mead Johnson & Co.
t Product of Wyeth, Incorporated.

The Journal-Lancet

Dosage. As to dosage, this varies with the individual
condition. Co Tui cited figures to substantiate the
thought advanced by others that the protein loss in op-
eration varies directly with the severity and duration of
the operation. As a guide I might quote the level of
adequate intake as determined by him in the case of
four surgical procedures:

1. Gastrectomy — .25 to .42 grams nitrogen/ K.B.W.

2. Cholecystectomy — .224 to .339 grams N./K.B.W.

3. Appendectomy — .184 to .350 grams N./K.B.W.

4. Herniotomy — .147 to .182 grams N./K.B.W.

Conclusion

In conclusion, may I state that the purpose of this
paper is primarily to draw attention to the fact that
protein deficiencies are probably more common than has
been considered. Elman of St. Louis has made the state-
ment that "Many doctors have in the past and tend to-
day to view an inadequate protein intake with compla-
cency.’’ A review of present-day information and a wider
clinical application in medicine can prove both a prophy-
lactic and therapeutic aid.

Bibliography

1. Protein Nutrition in Health and Disease. A Series of
Nine Articles Prepared Under the Auspices of the Council on
Foods and Nutrition of the American Association.

2. Cohn, E. J.; Oncley, J. L.; Strong, L. F.; Hughes, W.
L. Jr., and Armstrong, S. H. Jr.: The Characterization of the
Protein Fractions of Human Plasma. J. Clin. Invest., 23:417-
432 (July), 1944.

3. Madden, S. C., and Whipple, G. H.: Plasma Proteins:
Their Course, Production and Utilization. Physiol. Rev., 20:194-
217 (April), 1940.

4. Rose, W. C.; Haines, W. J.; Johnson, J. E., and War-
ner, D. T.: Further Experiments on Role of Amino Acids in
Human Nutrition. J. Biol. 148:457-458 (May), 1943.

5. Sherman, H. C.; Gillet, L. H., and Osterberg/TL: The
Protein Requirement of Maintenance in Man and the Nutrition
Efficiency of Bread Protein. J. Biol. Chem., 4E97-109 (Jan.),
1920.

6. Randin, I. S.; McNamee, H. G.; Kamholz, J. H., and
Rhodes, J. E.: Effect of Hypoproteinemia on Susceptibility to
Shock Resulting from Hemorrhage. Arch. Surg., 48:491-492
(June), 1944.

7. Cutherbertson, D. P.: Further Observations on the Dis-
turbance of Metabolism Caused by Injury with Particular Ref-
erence to the Dietary Requirements of Fracture Cases. Brit.
J. Surg., 23:505-520 (Jan.), 1936.

8. H.rschfield, J. W.; Williams, H. H.; Abbott, W. E.;
Heller, C. G., and Pilling, M. A.: Significance of the Nitrogen
Loss in the Exudate from Surface Burns. Ann. Surg., 15:766-
773 (May), 1944.

9. Block, R. J., and Bolling, D.: The Amino Acid Com-
position of Proteins and Foods. Chas. C. Thomas, Springfield,
111., 1945.

10. Rose, W. C.: Science, 86:298, 1937.

11. Elman, R.: J A M. A., 128:659-664 (June 30), 1945.

12. Elman, R.: Ann. Surg., 112:594, 1940.

13. Mulholland, J. H.; Co Tui, F.; Wright, A. M., and
Vince, V. J.: Ann. Surg., 117:512, 1943.

14. Taylor, F. H. L.; Levenson, S. M.; Davidson, C. S.;
Adams, M. A., and McDonald, H.: Science, 97:423, 1943.

15. Co Tui, F.: Clinical Experience with Oral Use of Pro-
tein Hydrolysates, presented before the New York Acad, of
Sciences, Dec. 1945.

16. Co Tui, F.; Wright, A. M.; Mulholland, J. H.; Ca-
rabva, V.; Barcham, L., and Vince, V. J.: Sources of Nitro-
gen Loss Post gastrectomy and Effect of High Amino Acid and
High Caloric Intake on Convalescence. Ann. Surg., 120:99-
122 (July), 1944.

17. The helpful aid of Mr. Wm. Murphy, representative of
Wyeth Co., and Mr. Lincoln Thomas, representative of Mead
Johnson and Co., in securing material and reprints is gratefully
acknowledged.

December, 1946

403

Surgery of the Stomach

O. Theron Clagett, M.D.*

Rochester, Minnesota

IT is impossible at any one time to attempt to discuss
all the phases of gastric surgery. However, it is well,
occasionally, to review various common lesions of the
stomach for which surgical treatment may be necessary
in light of newer developments in this field. A revalua-
tion of the older procedures and an evaluation of the
newer ones are necessary if the physician is to give his
patients his best advice.

Duodenal ulcer is probably the most common lesion
with which one is confronted. Unfortunately, the inci-
dence of duodenal ulcer seems to be increasing rather
than decreasing. It is still predominantly a disease of
men but women are afflicted with increasing frequency.
Duodenal ulcer is still primarily a medical disease and
I am convinced that it should remain so. Most people
who have duodenal ulcer, providing they will follow a
medical program and make the adjustments in their lives
that are necessary, can get along satisfactorily on med-
ical management. Unless one of the indications for sur-
gical treatment considered in subsequent paragraphs is
present, patients should have a thorough trial on med-
ical management.

There are, however, definite indications for surgical
treatment of duodenal ulcer. These indications are: (1)
perforation, (2) obstruction, (3) hemorrhage and (4)
intractability. There can be no argument that perfora-
tion of a duodenal ulcer constitutes a surgical emergency.
It is generally agreed that operation should be done as
soon as possible. A simple closure of the ulcer without
any attempt to do anything further is the treatment of
choice in most cases. Occasionally there may be so much
obstruction at the duodenum that it may be necessary to
perform gastro-enterostomy at the same time that closure
is carried out. It is not justifiable to consider gastric
resection as a treatment for perforated duodenal ulcer.
This has been advocated but it is a radical procedure
which inevitably carries considerably greater risk than
simple closure. The results of simple closure in general
have been excellent. In our experience in the Mayo
Clinic, only about 20 per cent of all patients that have
undergone closure of acute perforation have ever re-
quired any subsequent gastric operation.

Obstruction at the outlet of the stomach constitutes
a second definite indication for surgical treatment. If
the obstruction is due to an old burned-out cicatricial
ulcer and the patient is past fifty years of age and the
concentration of gastric acids is not high, gastro-enter-
ostomy is still a very satisfactory procedure. However,
if the obstruction is due to edema around an acutely in-
flamed duodenal ulcer and the patient has a high con-
centration of acids, it may be advisable to perform gas-
tric resection instead of gastro-enterostomy. It should

*Division of Surgery, Mayo Clinic, Rochester, Minnesota.
Read before the meeting of the Montana State Medical As-
sociation, Great Falls, Montana, July 19-20, 1946.

always be remembered, however, that the most vulnerable
part of a gastric resection is the duodenal stump, and
that in cases in which there is a very marked reaction
around the duodenum and in which the tissues are edem-
atous, friable and indurated, it may be impossible to ob-
tain a satisfactory closure of the duodenal stump. In
such cases the risk of gastric resection may be too great
and gastro-enterostomy be preferred.

If the patient is more than forty years of age bleed-
ing duodenal ulcer should be looked on with concern
because it is well known that patients of this age and
beyond may have an exsanguinating and even fatal hem-
orrhage from these ulcers. Younger patients tolerate
hemorrhage and usually their hemorrhages are not as
severe as those of older patients. Because of the danger
of fatal hemorrhage, patients more than forty years of
age who have recurrent hemorrhages from a duodenal
ulcer should be considered candidates for operation pro-
viding their general condition will p>ermit surgical treat-
ment. If possible, the operation should be performed
in the interval between hemorrhages. The danger of op>-
erating on patients while they are bleeding is well known
and operation should not be attempted unless an ade-
quate supply of blood for transfusion is available. Gas-
tric resection rather than gastro-enterostomy is the treat-
ment of choice for bleeding duodenal ulcers.

Some duodenal ulcers which have not perforated, have
not become obstructing, and have not resulted in hemor-
rhage, justify surgical treatment because of their in-
tractability to medical management. This typ>e of ulcer
is usually on the posterior wall of the duodenum, per-
forates into the pancreas and produces severe pain,
which is not effectively relieved by medical management.
The pain often wakes the patient at night and inter-
feres with his rest so that it is impossible for him to
continue working. This pain may be very severe, even
requiring opiates for relief. A patient who has a duo-
denal ulcer with severe pain that interferes with health
and work in spite of good medical management should
certainly be offered the benefit of surgical relief. Partial
gastrectomy is usually the operation of choice in these
cases.

A brief discussion regarding the place of gastro-enter-
ostomy and gastric resection in the treatment of duo-
denal ulcers is warranted. These two procedures are the
only ones that are practiced commonly at the present
time. Gastro-enterostomy has been completely condemned
by many surgeons. It certainly must be admitted that
its results have not all been what one would like them
to be. However, it cannot be denied that there is still
a place for gastro-enterostomy in the treatment of duo-
denal ulcer.

Gastro-enterostomy can be performed with minimal
risk and it will, providing it functions properly, result
in the healing of the duodenal ulcer. In those cases in

404

The Journal-Lancet

which there is an old cicatricial ulcer resulting in ob-
struction, gastro-enterostomy will accomplish as good re-
sults as gastric resection. It should also be performed
rather than gastric resection in those cases in which there
is so much inflammatory reaction around the duodenum
that it is impossible to resect beyond the pylorus and per-
form a closure of the duodenal stump that will be safe
and satisfactory. It is much better in these cases to per-
form gastro-enterostomy and then at a later time, after
the ulcer is healed, to perform resection if it seems nec-
essary.

Gastric resection does not inevitably produce a good
result. As more resections are followed for longer peri-
ods, a greater incidence of gastrojejunal ulcer after re-
section becomes apparent. I cannot agree with those
surgeons who say that if an adequate amount of stom-
ach is resected there will be no recurrence of the ulcer.
My colleagues and I have seen patients in whom more
than 90 per cent of the stomach has been resected but
a gastrojejunal ulcer has promptly developed. Resection
of more than three fifths of the stomach is not justifiable
in most instances. A more extensive resection carries
greater risk and it handicaps the patient by reducing the
size of his stomach unnecessarily. The increased danger
and disability of a very extensive resection are not justi-
fied by any reduction in the incidence of ulceration after
resection.

Gastric ulcer is a very different problem from a duo-
denal ulcer. There is still some difference of opinion as
to whether a gastric ulcer is primarily a medical or a
surgical disease. While duodenal ulcer is primarily a
medical disease, gastric ulcer is a surgical disease. I do
not intend to enter the controversy as to whether benign
gastric ulcers become malignant or are ulcerating carcino-
mas from their origin. Experience has now demonstrated
conclusively that all gastric ulcers must be looked on
with great concern since they may be or may become
malignant. There are many ulcerating lesions in the
stomach in which it is impossible to determine by roent-
genologic examination, by gastroscopy, by any clinical or
laboratory test, by palpation at the time of operation or
even by macroscopic examination of the resected lesion,
whether the lesion is benign or malignant. Only careful
microscopic examination of sections taken from several
parts of the lesion will provide accurate diagnosis of
these lesions.

Because this is true and because the risk of gastric
surgical treatment has been brought to such a low level,
one is now justified in advising operation on every pa-
tient who has an ulcerating lesion of the stomach, pro-
vided, of course, the patient’s general condition will
permit operation. From every standpoint early surgical
treatment of such lesions is preferable to a trial of med-
ical treatment before advising operation. From an eco-
nomic standpoint the length of hospitalization and dis-
ability is no longer for operation than for proper med-
ical treatment. When the lesion is removed surgically,
the patient is relieved of his disease and has nothing
further to worry about. When gastric ulcer is treated
medically the patient must follow a rigid dietary regimen

and must report back for re-examination at frequent
intervals. Very often after a long trial of medical man-
agement it is still necessary to resort to surgical treat-
ment and in those cases in which the lesion proves to be
malignant, the best opportunity to cure the patient has
been lost by this unnecessary delay. Nothing is lost by
surgical treatment even if the patient proves to have a
benign lesion at the time of operation. The results of
surgical resection for benign gastric ulcer are among the
best in all surgery. The risk of operation is slight. Re-
current ulcerations and complications are rare. When
one considers the impossibility of making an accurate
clinical diagnosis of ulcerating gastric lesions, the danger
of these lesions being malignant and the benefits to be
gained at minimal risk by surgical treatment, this aggres-
sive attitude toward ulcerating gastric lesions is justified.

Gastrojejunal ulcer is still a problem after either
gastro-enterostomy or gastric resection, and is certainly
a surgical problem. Gastrojejunal ulcers rarely respond
to medical management and usually require surgical
treatment. A gastrojejunal ulcer following gastro-enter-
ostomy can be successfully treated, in most instances, by
take-down of the gastro-enterostomy and partial gastrec-
tomy. It may be advisable, in the light of recent experi-
ence with resection of the vagus nerve, to section the
vagus nerve at the same time, or, in some cases, as an
alternative to take down the gastro-enterostomy and gas-
tric resection. Gastrojejunal ulcers which occur follow-
ing gastric resection should be treated by resection of
the vagus nerve. Re-resection of the stomach, provided
an adequate resection had been performed previously,
should not be considered. If a recurrent ulcer develops
after adequate gastric resection, this fact proves conclu-
sively that the patient’s ulcer-forming factors are very
strong and in such instances, resection of the vagus nerve
offers more relief than anything else.

A brief discussion of resection of the vagus nerve
should be given here. I am much impressed by the work
Dr. Dragstedt 1 has done in this regard. Dr. Dragstedt
is a conservative and honest investigator. He is a physi-
ologist as well as a surgeon and is most enthusiastic
about resection of the vagus nerve. I am hopeful that
his enthusiasm will continue to be warranted, but am
a little afraid to be too enthusiastic about the procedure
at the present time. So many treatments and surgical
procedures for the treatment of duodenal ulcer have been
proposed and proved disappointing that resection of the
vagus nerve may follow the same pattern. The early
results are most encouraging but too few cases have
been studied long enough to permit an accurate evalua-
tion of the procedure as yet. There is no question that
it is an easy and safe procedure, and if it continues to
be as effective as early appearances indicate, it will un-
doubtedly supplant most of the other surgical procedures
used in the treatment of duodenal ulcer. Resection of
the vagus nerve should not be used in the treatment of
gastric ulcers instead of removal of the lesion because
here, as mentioned earlier, it is impossible to determine
which lesions are malignant and which are not before
the operation is performed. For the present, I have used

December, 1946

405

resection of the vagus nerve only in those cases in which
an ulcer has developed after gastric resection. Here it
has seemed effective. The great disadvantage of vagoto-
my apparently is the fact that it reduces the motility of
the stomach so that sometimes the stomach becomes
quite large and atonic and occasionally gastro-enterostomy
is necessary to facilitate its emptying. What late side
effects to other organs may result from resection of the
vagus nerve have not been determined.

Carcinoma of the stomach is still the most frequent
carcinoma with which one is confronted. It is discour-
aging in considering this most common of carcinomas
to be forced to admit the highest death rate and the
lowest cure rate in all cancer surgery. About one fourth
of all deaths from carcinoma are estimated to be due
to carcinoma of the stomach. What can be done to
better this situation? At present there are apparently
only three ways to attack this problem. First come fun-
damental researches into the cause of cancer, factors
predisposing to its development and means of prevent-
ing its development. Thus far, work in this field has
not been productive but it is hoped that progress will be
made in the future. Second, carcinoma of the stomach
must be diagnosed earlier so that patients can be brought
to the surgeon while the lesion is still operable. This
requires education of the public as to their responsibility
in seeking medical attention, and, just as important,
education of the medical profession in using adequate
methods of diagnosis to discover or rule out the pres-
ence of carcinoma in patients who present themselves
with suggestive symptoms. Third, surgical treatment of
carcinoma of the stomach must be made more effective
by extending the limits of radical operation. I shall con-
cern myself with the surgical treatment of cancer of the
stomach and the methods by which the limits of opera-
tion may be extended and the results of surgical treat-
ment improved.

In planning any surgical attack on cancer of the
stomach, one must consider the four routes by which
these growths may spread: (1) direct extension within
the stomach and invasion of surrounding organs; (2)
lymphatic spread through the extensive lymphatic sys-
tem within and surrounding the stomach; (3) hemat-
ogenous spread with metastasis to distant organs, liver,
and so forth; (4) implantation of malignant cells on
peritoneal surfaces. The radical surgical treatment of
cancer of the stomach must take these characteristics of
cancer of the stomach into consideration. The operation
should aim at excising in one block the entire lesion,
as much of the stomach and surrounding structures as
may conceivably be involved by direct spread, and the
entire lymphatic system draining this region. Finsterer ~
first suggested, and recently, Coller and Kay 3 have
re-emphasized the importance of including the entire
greater omentum in any resection for carcinoma of the
stomach because of the frequent involvement of lym-
phatic vessels and nodes in this structure.

All the usual operations performed for carcinoma of
the stomach are modifications of the original Billroth I
and Billroth II procedures. It does not make a great

deal of difference what type of partial or sub-total gas-
trectomy is performed for carcinoma of the stomach
provided the operation accomplishes a sufficiently radical
removal of the lesion and its lymphatics. I have a per-
sonal preference for a modification of the Billroth I
operation. As carcinoma of the stomach rarely extends
over into the duodenum, the duodenum is usually suf-
ficiently mobile to permit a satisfactory anastomosis.
I have found that I can remove up to three fourths or
four fifths of the stomach in many cases and remove
the entire lesser curvature, make an oblique closure of
the lesser curvature portion of the end of the stomach
and still bring the greater curvature portion of the end
of the stomach to the duodenum and make an anasto-
mosis without tension. The operation is quicker and
easier to perform than the various Billroth II or Polya
types of operations and accomplishes just as radical a
resection. It is a more physiologic type of operation.
My impression has been that these patients have a
smoother postoperative course and become adjusted to
their gastric resections more easily than to operations
involving anastomosis of the stomach to the jejunum.
The Billroth I type of operation has fallen into some
disrepute because of the alleged danger of leakage at
the angle where the closure of the lesser curvature por-
tion of the end of the stomach and the anastomosis
come together. Personally, I have had no difficulty of
any kind with this problem and prefer this operation
when conditions will permit.

Since it is impossible in most instances to diagnose
carcinoma of the stomach at an early and favorable
time for resection, surgeons have been forced for the
most part to deal with extensive lesions. In order to im-
prove the rate of resectability and end results, surgeons
have devised technics for more extensive and radical op-
erations. Total gastrectomy for lesions involving the
entire stomach and transthoracic resection for lesions of
the cardia and lower part of the esophagus have been
outstanding developments of these efforts.

Total gastrectomy is a formidable operative procedure.
The mortality rate of the operation is unavoidably high.
However, there are many instances in which this pro-
cedure offers the patient his only chance. Every surgeon
who undertakes gastric surgery should have sufficient
training and experience to enable him to perform the
operation when necessary. Total gastrectomy is not
a new procedure. The feasibility of the procedure was
suggested by Albert 4 in 1880. It was first carried out
by Conner ° of Cincinnati in 1884 but the patient did
not survive. The first successful total gastrectomy re-
ported was performed by Schlatter 6 in Switzerland in
1897. The patient lived about fourteen months. By
1943 Pack and McNeer 7 were able to report a series of
303 cases of total gastrectomy. They collected 283 cases
from the literature and added 20 cases from their own
experience. There have been reports of many additional
cases since their study was made. Total gastrectomy is
now a relatively common operation. Its technical diffi-
culties, the metabolic abnormalities consequent to it, the

406

The Journal-Lancet

Fig. 1. End-to-side esophagojejunostomy with jejuno-
jejanostomy.

Fig. 2. End-to-end esophagojejunostomy with end-to-side
jejunojejunostomy.

refractory anemia, the postoperative complications and the
high mortality rate of the operation all serve to contra-
indicate its use except as an operation of necessity. How-
ever, many of the problems and difficulties regarding
both the technical factors of the operation and post-
operative complications have been solved and there is no
excuse for denying a patient the benefit of the operation
if a less radical procedure is not sufficient.

There are a variety of technics for the establishment
of continuity of the esophagus to the small intestine after
total gastrectomy. Figures 1, 2 and 3 illustrate some of
the methods available. I have tried all these methods
and have no great preference for one over another.
Esophagoduodenostomy has many advantages when tech-
nically feasible and it is a quicker, easier operation to
perform. There is only one line of suture for the anasto-
mosis and it offers the best physiologic restoration pos-
sible. However, in many instances it is impossible to
make the anastomosis without tension and it must be
remembered that both the distal portion of the esopha-
gus and the proximal portion of the duodenum lack a
rich blood supply. If esophagoduodenostomy is not pos-
sible, the various types of esophagojejunostomy are quite
satisfactory.

December, 1946

407

Pack and McNeer have pointed out that a procedure
that is so technically difficult, which is followed by many
immediate and late complications, which up to 1942 had
a mortality rate averaging 37 per cent, and which up to
1942 had resulted in only sixteen patients surviving their
operation more than three years, is not likely to meet
with much favor. All this is certainly true but, on the
other hand, there is no excuse for the development of
a spirit of defeatism. Progress in surgery is such that
it is not wise to make predictions for the future based
on experience of the past. Total gastrectomy is never
an operation of choice but is always an operation of
necessity. Figure 4 indicates the more aggressive atti-
tude that my colleagues and I are adopting. Since 1940
the frequency with which total gastrectomy has been
performed has nearly tripled. With increasing experi-
ence the technical difficulties are being overcome, the
risk of operation is being decreased and many of the
immediate and late complications are being avoided.
If progress is to be made in the surgical attack on
cancer of the stomach, total gastrectomy must be per-
formed more frequently.

The development of the transthoracic approach to
lesions of the cardia of the stomach fills a long-felt need
in gastric surgery. Previous to the development of this
procedure, many patients were denied the benefits of
operation because of the anatomic location of the lesion.
Since about 10 per cent of all carcinomas of the stomach
occur in the cardia, it becomes apparent that this pro-
cedure can extend considerably the rate of resectability
for malignant lesions of the stomach. The transthoracic
approach to lesions of the cardia involving the lower
part of the esophagus and producing dysphagia permits
adequate exposure for wide resection of the lesion and
the regional lymph nodes and maintenance of esophago-
gastric continuity. Pathologic studies have shown clearly
that whereas there is a block mechanism which is quite
effective in preventing extension of cancer beyond the
pylorus into the duodenum, there is no such mechanism
at the cardia. Instead there is a tendency for the cancer
to extend along the submucosa up the esophagus, often
to such an extent that even the most radical total gas-
trectomy possible by the abdominal route will not be suf-
ficient to remove the entire malignant process. Opera-
tion by the transthoracic route is the only procedure
which will permit adequate resection of the lower part
of the esophagus, the growth in the stomach, and the
regional lymph nodes in carcinomas of the cardia in
which there is dysphagia.

Removal of carcinoma of the cardia by the trans-
thoracic approach is an operation based on sound sur-
gical principles. Its development provides another weap-
on for an attack on cancer of the stomach.

In reviewing our experience with carcinoma of the
stomach from 1930 to 1944, inclusive (figure 5), it is
interesting to note that the ratio of patients who were
operated on to patients on whom a diagnosis was made
has remained about the same, that is, in the neighbor-
hood of 60 to 65 per oent. In other words, in spite of

Fig. 4. Increase of frequency with which total gastrecto-
my has been performed.

all efforts to educate the public and the medical profes-
sion regarding the importance of early diagnosis of
cancer it has not been possible to increase the proportion
of patients whose lesion is not too extensive to permit
a consideration of surgical exploration. This is a most
discouraging fact. That surgeons have extended the
limits of operation is indicated, however, by the fact that
the ratio of patients who underwent resection to the
patients operated on increased from about 42 per cent
in 1930 to about 60 per cent in 1944. It is most encour-
aging to mention that whereas the mortality rate of
resection for carcinoma of the stomach averaged 16.2
per cent from 1907 to 1938, by 1942 the risk had de-
creased to 6.7 per cent and in 1943 and 1944 to only
5 per cent and in 1945 to 2.8 per cent. This reduction
of the operative mortality rate for carcinoma of the
stomach is encouraging, particularly since it occurred
during the period in which the limits of resection were
being extended to include total gastrectomy and trans-
thoracic gastrectomy, procedures which are necessarily
accompanied by a high operative mortality rate.

While I do not want to be pessimistic, I do not see
at the present time how one can anticipate much further
improvement in the results of surgical treatment of car-
cinoma of the stomach. The rate of resectability has
gone about as high as it can go until patients are brought
to the surgeon at a more opportune time than they are
at present. There is room for some improvement of the
operative mortality rate to be sure, but it seems unlikely
that the rate can be reduced much until patients are
brought to the surgeon in more favorable condition for
operation. Surgeons must continue their efforts but real
solution of the problem of carcinoma must come from
other sources. Means of preventing the development of
cancer of the stomach or of diagnosing the presence of
cancer in its very early stages seem to be the only satis-
factory solution at the present time.

408

The Journal-Lancet

Malignant Lesions of the Stomach

Ratio of patients operated on to patients with

| diagnosis j|l (surgical rate)

U 30
20
10

— ^— /

N/ \/

Ratio of patients who underwent resection to

patients operated on (resectability rate) s

Ratio of patients who underwent resection to"
total patients with diagnosis

#- — ♦ — -

1930 31 32 33 34 35 36 37 38 39 40 41 42 43 1944

Year

Fig. 5. Rate of resectability for carcinoma of the stomach.

References

1. Dragstedt, L. R.: Personal communication to the author.

2. Finsterer: Quoted by Ogilvie, W. H.: The Approach to
Gastric Surgery. Lancet, 2:235 (July 30) ; 295 (Aug. 6), 1938.

3. Coller, F. A.; Kay, E. B.; and M’Intyre, R. S.: Regional
Lymphatic Metastases of Carcinoma of the Stomach. Arch.
Surg., 43:748 (Nov.), 1941.

4. Albert: Quoted by Pack, G. T., and McNeer, Gordon.

5. Conner, P. S.: Quoted by Pack, G. T., and McNeer,

Gordon

6. Schlatter, C.: Quoted by Pack, G. T., and McNeer,

Gordon.

7. Pack, G. T., and McNeer, Gordon: Total Gastrectomy
for Cancer; a Collective Review of the Literature and an
Original Report of Twenty Cases. Internat. Abstr. Surg.,
77: 265 (Oct.), 1943.

NEW MONTHLY JOURNAL,

POSTGRADUATE MEDICINE,

TO APPEAR IN JANUARY, 1947

This new journal is to be the official publication of the
Interstate Postgraduate Medical Association of North
America and will present the type of articles which the
average general practitioner will find most useful and
needful in his own practice. The source of most of the
basic material will be the addresses and diagnostic clinics
which are presented at the annual meetings of this asso-
ciation, supplemented by new material originating in
various postgraduate centers.

Just as the addresses in the meetings have stressed the
informal type of doctor to doctor discourse so will Post-
graduate Medicine maintain this same approach. The

editorial emphasis will be centered on therapy, substan-
tiated by an unusually fine graphic presentation.

Among special features to appear in the contents are:
This Month in Medicine, a review of medical events and
meetings; a department of clinical photography; a con-
sultation service; Association Notes, news concerning cur-
rent activities of the Interstate Postgraduate Medical
Association; and clinical information on new drugs and
instruments.

The business manager is Paul K. Whipple, 515 Essex
Building, Minneapolis, Minnesota. The subscription price
is $8.00 per year.

December, 1946

409

Tuberculosis Control in Colleges and Universities*

J. Arthur Myers, M.D.

Minneapolis, Minnesota

Improved Situation Encouraging

When the original Committee on Tuberculosis of
the American Student Health Association was
appointed in 1931 an extremely serious tuberculosis prob-
lem existed in many of our colleges and universities. In
very few institutions was any search being made for the
disease among entering students or in the various classes
already enrolled. Nowhere had a routine procedure been
established for the control of the disease among faculty
and other members of the personnel. Tuberculosis was
diagnosed among students and personnel in most schools
only when severe symptoms appeared, such as pulmonary
hemorrhage. In many of these cases the disease had been
contagious over a considerable period of time and, there-
fore, such persons had disseminated tubercle bacilli
among their associates. In one case a senior medical stu-
dent was within three weeks of death when his disease
was diagnosed. Two years later four of his fraternity
brothers were under treatment for pulmonary tubercu-
losis. In another school a student had been failing in
health for several months before he was known to have
advanced, contagious tuberculosis. During the next ten
years twelve of his fraternity brothers died from this
disease. In some instances when students were found to
have tuberculosis, they stated that the only known con-
tact had been with tuberculous faculty members.

In the fifteen years of its existence the Committee on
Tuberculosis (directed by Chairmen Ferguson, Lyght,
Lees, and Durfee) has made tremendous strides in stim-
ulating control of the disease in many institutions. Un-
fortunately, there are many other colleges that have not
availed themselves of the well-established, practical pro-
cedures, and much remains to be done even in those in-
stitutions that have done the best work up to the pres-
ent time.

Complete Control Possible
Today enough information is available concerning the
diagnosis, treatment and prevention of tuberculosis so
that its control can be established and maintained on any
campus. However, this requires eternal vigilance and
"taboo” of slipshod and short-cut methods. The prac-
tical procedures are so simple and inexpensive that the
members of a Health Service Staff who fail to use them
may be regarded as indifferent, uninformed, or misin-
formed. In even worse circumstances is the school which
does not provide for an adequate Health Service Staff,
both professional and clerical. Such an institution is
deserving of the most severe criticism, since the health of
the individual is his most priceless asset, both during his
student days and thereafter. Therefore, no department
of an institution is more important than the Health

*From the Student Health Service and the School of Public
Health of the University of Minnesota. Presented before the
twenty-fourth annual meeting of the American Student Health
Association, May 9, 1946.

Service, and no college or university is complete without
such a modern first class service.

Diagnostic Procedures

The first step in tuberculosis control consists of ascer-
taining who among the entering students or the person-
nel have the disease or develop it while on the campus.
The only way this can be determined with accuracy is
through the use of the tuberculin test. (We no longer
use the terms "negative reactors” and "positive reactors”
but rather the words "reactors” and "non-reactors.”)
The body of everyone who reacts characteristically to
tuberculin harbors tuberculous lesions in which living
tubercle bacilli exist. The tuberculin reaction does not
coincide with symptoms or physical signs, including X-ray
shadows, because these are manifestations only of gross
and often advanced disease. However, it does closely
tally with postmortem findings, provided the examina-
tion is made in sufficient detail. The individual who has
no evidence of the disease, except the tuberculin reaction,
has tuberculosis just as truly as the one who is dying
from tuberculous meningitis or chronic pulmonary lesions;
the difference is only one of degree. In one case the
lesions have not evolved so that their location can be
determined by our present crude methods of examina-
tion, while in the other they have progressed to fatal
termination. The tuberculin test determines the presence
of the disease in all of its stages of evolution, with cer-
tain well-known but unimportant exceptions, particularly
during the pre-allergic stage of three to seven weeks and
sometimes in terminal conditions.

A characteristic tuberculin reaction justifies an abso-
lute diagnosis of at least primary or the first infection
type of tubercuolsis. This type of the disease is indubi-
tably prerequisite to the development of all acute and
chronic reinfection forms. Indeed, somewhere in the
body of every person who dies from tuberculosis the pri-
mary lesions can be found which definitely antedated
the destructive and fatal lesions, if sufficiently careful
search is made for them. The exact percentage of per-
sons with primary tuberculosis, as manifested by the tu-
berculin reaction, who subsequently develop reinfection
or clinical types of the disease has never been accurately
determined. However, the careful analysis of Bogen in-
dicates that it is about 50 p>er cent. Excellent support for
this figure is to be found in places where primary tuber-
culosis develops by early adult life in nearly the entire
population. Here one finds tuberculosis is responsible for
one-fourth to one-third of the deaths from all causes.
Certainly not all persons who develop the reinfection
type of lesions die from the disease; indeed, many of
them are never incapacitate. Therefore, Bogen’s state-
ment to the effect that one-half of the persons with pri-
mary tuberculosis subsequently develop reinfection types
probably closely approaches the actuality. In any event,
no one falls ill or dies from tuberculosis without first hav-

410

ing developed the primary type of this disease. There-
fore, it behooves every Health Service to determine by
the tuberculin test just who has primary tuberculosis and
to examine promptly all such persons for the reinfection
type of the disease on admission and periodically while
they are on the campus, and to instruct them to have
periodic examinations throughout the remainder of their
lives. Failure to use the tuberculin test routinely and
periodically is to omit or ignore the most important phase
of tuberculosis control work on any campus.

Both Old Tuberculin and PPD are satisfactory test-
ing materials. However, they must be obtained from re-
liable sources and so treated that their potency is guar-
anteed and maintained. The intracutaneous method of
administration of Mantoux is the most satisfactory. For
those who do not react to the first dose (0.1 mgm. of
Old Tuberculin or 0.00002 mgm. of PPD) the second
dose (1.0 mgm. of Old Tuberculin or 0.005 of PPD)
should be administered. The test should be read 72 to
96 hours later. A reaction is present only when there
is an area of edema or induration, or both, of five milli-
meters or more in diameter. This may or may not be
surrounded by an area of hyperemia. When induration
is present less than five millimeters in diameter, it should
be recorded as a questionable reaction. In such cases it
is possible that a recent infection has occurred and the
sensitivity of the tissues has not reached a degree which
will result in a characteristic reaction. Again, primary
lesions may be present of such long standing that the
allergy has waned and has reached such a low level that
the initial dose of tuberculin does not elicit a character-
istic reaction. In all such cases the test should be re-
peated within a few weeks, and if there remains only a
questionable reaction to the second dose, larger amounts
should be administered.

All tuberculin reactors have primary lesions and should
be watched carefully for the appearance of reinfection
forms of the disease. Those persons who do not react
to tuberculin on entrance to a school should have the
test repeated annually so that the few who become in-
fected for the first time each year may be observed sub-
sequently in the same manner as those who enter as
reactors.

One reason that some Health Services do not use the
tuberculin test is that members of the staff are laboring
under the delusion that all young adults have primary
tuberculosis (tuberculous infection) and, therefore, would
react to the tuberculin test. While this may have been
true forty or fifty years ago, the situation has changed
so remarkably in recent years that now on most cam-
puses only a relatively small percentage of the students
have primary tuberculosis and, therefore, react to tuber-
culin. Indeed, the Committee on Tuberculosis of the
American Student Health Association, in reporting for
the school year 1942-1943, pointed out that among 208
colleges, representing a total student enrollment of
300,144, the incidence of reactors was only 18.6 per
cent. That year thirteen colleges reported that less than
10 per cent of their students were reactors. The next
year the Committee said: "It is sound practice and in
the interest of economy to provide chest roentgenograms

The Journal-Lancet

for only those students who react to an adequate dose
of tuberculin.”

The incidence of tuberculin reactors has definitely de-
creased from year to year. In fact, during the school
year 1932-1933 the Committee reported that 35 per cent
of the students tested were found to be reactors. On
the first routine testing of students at the University of
Minnesota in 1928 the incidence of reactors was 33 per
cent whereas in 1945 it was less than 10 per cent. There-
fore, the number of students who have primary tubercu-
losis on most campuses is now so small that it is phys-
ically possible to keep them under close surveillance.

Routine and periodic testing of students provides our
only satisfactory criterion of an effective tuberculosis con-
trol program, both on the campus and in the community
from which the students are derived.

From most institutions reports of the existence of pri-
mary tuberculosis among the students have been exceed-
ingly misleading since they obviously have included only
those who presented such X-ray evidence as of calcium
deposits, etc. In reality, this is only a sprinkling of those
who actually have primary lesions. Moreover, from cer-
tain sections of the country, particularly Arizona, Cali-
fornia, Colorado, and New Mexico, and the states in the
Central-Eastern half of the country, extending from
Kansas City to the East Coast, it now appears that more
of the calcium deposits are due to fungus diseases (par-
ticularly coccidioidomycosis and histoplasmosis) than to
tuberculosis. The recent work of Palmer emphasizes the
great importance of specific tests in diagnosis. Since
coccidioidin and histoplasmin are available, as well as
tuberculin, there is no excuse for reporting the presence
of primary tuberculosis, even when calcium deposits are
in evidence, unless the individual reacts characteristically
to tuberculin. Indeed, in the whole examination for tu-
berculosis there are only two phases that yield specific
evidence, of which tuberculin is one.

In some institutions X-ray inspections of the chests of
students and personnel have been adopted to the exclu-
sion of all other phases of the examination. This is bet-
ter than having no program at all but it is far from ade-
quate. X-ray inspection reveals evidence only of gross
pathology. Nevertheless it is extremely useful when prop-
erly employed because it often, and in fact usually, is
capable of revealing the location of lesions before symp-
toms are present or other physical signs can be elicited.
Therefore, it should be used routinely and periodically
to inspect the chests of all tuberculin reactors, but never
to the exclusion of other phases of the examination.
Because some exaggerated and completely unfounded
statements have been made concerning the value of
X-ray, it is necessary to emphasize its limitations:

1. On the usual single X-ray film with postero-anterior
exposure, one visualizes only about 75 per cent of the
lungs, the remainder being obscured from view by shad-
ows of such structures as the heart and diaphragm.

2. X-ray shadows are never pathognomonic. Those
produced by various other diseases may have exactly the
same appearance as those cast by tuberculous lesions.
In all cases the etiological agent is microscopic but we
inspect the X-ray shadows with the naked eye. More-

December, 1946

411

over, the pathologist at the postmortem table, when he
views the lesion directly with his naked eye and palpates
it, is still compelled to use the microscope to make ac-
curate diagnoses. Thus, it is fallacious to attempt to
make diagnoses only from the shadows of lesions on
X-ray films.

The deposition of calcium in the lungs and hilum
regions is not a specific process, since it results from
numerous conditions. Therefore, it is absurd to use in
an X-ray report such terms as Ghon’s tubercle, primary
lesions or complex, and old healed tuberculosis , whenever
evidence of calcium deposits is seen on X-ray films.

3. Among the students and personnel of any campus
at any given time there is far more pre-X-ray tubercu-
losis than that of visible X-ray proportion. Indeed,
among persons recently infected with tubercle bacilli,
as soon as allergy can be elicited by the tuberculin test,
only 5 to 10 per cent present X-ray shadows which might
be due to tuberculosis; in the remaining 90 to 95 per
cent the films of the chest are entirely clear. A few years
later, however, X-ray shadows which could be due to
tuberculosis may be visualized in a higher percentage,
but nearly always in less than 20 per cent. The increase
is due to the deposition of calcium in some of the lesions.
Even when this is seen one is never sure that it is in a
tuberculous lesion. Thus, X-ray inspection of the chest
practically never reveals evidence of primary tuberculosis
in more than 20 per cent of the persons in whom lesions
exist. The remaining 80 per cent have clear X-ray films
throughout life, as far as this type of tuberculosis is con-
cerned.

Some of the reasons that the X-ray is of so little help
in the detection of primary lesions are: (a) Many of
them never attain sufficient size or consistency to absorb
X-rays so that shadows are cast which can be seen by the
unaided eye; (b) many primary lesions are located in
portions of the lungs which are obscured from view and
are not visualized on an X-ray film, even though they
are macroscopic in size. A considerable percentage of
lesions never calcify, (c) An appreciable number of per-
sons with primary tuberculosis have the lesions only in
extrathoracic parts of the body. Therefore, any Health
Service employing only the X-ray as a diagnostic agent
will fail to identify at least 80 per cent of the students
and personnel who have primary tuberculosis.

Much of the reinfection type of chronic pulmonary
tuberculosis is also of pre-X-ray proportion over a consid-
erable period of time. Therefore, despite the fact that
these lesions are developing, they are completely missed
by X-ray. However, as they progress there comes a time
in their evolution when there is X-ray evidence, but it is
so slight that one must refer to the area as questionable.
Often such evidence is proved to be important only after
the lesion has progressed so that unmistakable shadows
are cast on the X-ray film. On the other hand, there are
cases (and they are probably more numerous than we
have previously realized) whose chest X-ray films are
clear on one day and within three to six months so much
shadow is present that they must be classified as mod-
erately or far advanced. Some of these are thought to

be due to hematogenous dissemination of large numbers
of tubercle bacilli over extensive areas of lung tissue.

Those who maintain that X-ray inspection of the chest
is an adequate tuberculosis control measure must be
shocked to know that of 18 million persons examined for
military service in the last few years, 180,000 were re-
jected largely because of X-ray shadows. In some places
these rejectees were adequately examined subsequently
and the figures to date indicate that about 10 per cent
had no shadow whatsoever a few weeks after the rejec-
tion. This suggests that they probably had lesions of
acute infections, such as pneumonia, which were mis-
taken for tuberculosis at the induction centers. Active
tuberculosis existed in far less than 50 per cent of those
whose X-ray shadows resulted in rejection for this dis-
ease. In fact, the figures have varied from approximately
4 per cent in one section of Illinois to 37 per cent in
New York City. The observations available thus far
suggest that not more than one-fifth to one-fourth of
the persons rejected for military service because of tuber-
culosis actually had this disease in significant clinical
form. Another shocking fact is that in two-thirds of
all persons discharged from military service because of
tuberculosis during the first two years of the war, there
were definite shadows on the induction films which were
either overlooked or ignored. Although students of tuber-
culosis have long known that X-ray inspection of the
chest alone is wholly inadequate in a tuberculosis control
program, the evidence on such a large group of indi-
viduals had never before been brought into bold relief.
While this kind of work may be excusable during a
war emergency, it can never be justified in a Student
Health Service.

The size of type of X-ray film to be used on any
campus apparently is of little significance. Prior to 1918
chest X-ray exposures were made on glass plates coated
with a sensitized emulsion; these were cumbersome,
heavy, and easily broken. The U-boat warfare having
cut off the supply of glass from Europe, the celluloid
film was substituted and generally adopted. However,
it was greeted with much opposition on the part of many
physicians who were long accustomed to using glass
plates.

Beginning in 1932 another heated controversy was
waged with reference to the efficacy of paper films.
Those who used them extensively contended that they
are as efficacious as celluloid films in determining the
location of demonstrable lesions in the lungs. On the
other hand, those who had used them little or not at all
severely condemned them. A similar debate ensued when
microfilms were introduced into this country by Lindberg
in 1938.

In 1945 films of the chests of a large number of
individuals were made successively on 14xl7-inch cellu-
loid, 14xl7-inch paper, 4xl0-inch stereo photofluoro-
grams, and 35-millimeter photofluorograms. These films
were carefully studied by a committee composed of three
chest specialists and two radiologists, who concluded that
all four methods are equally reliable from the standpoint
of case-finding. The committee pointed out that such
advantage as may be inherent in any one technic is of

412

The Journal-Lancet

so small a magnitude that it is very much smaller than
the human error involved in X-ray inspection.

The Diagnosis

X-ray film inspection of the chest is only one phase
of the physical examination for tuberculosis. Palpation,
percussion, and auscultation should always he employed.
Occasionally, lesions lying near the periphery of the lung,
particularly in and above the axillary region, may pre-
sent no shadow on the X-ray film, and yet other phases
of the examination, particularly auscultation, reveal evi-
dence of their presence. Moreover, no examination of
tuberculin reactors should be limited to the chest. In an
appreciable number of tuberculous persons ( 10 per cent
or more) the lungs may be entirely free from demon-
strable disease, yet clinical lesions are present in various
other parts of the body, such as the bones, joints, and
kidneys. For this reason the entire body should always
be examined. Indeed an individual may be within a few
hours of death from tuberculous meningitis or miliary
disease, and yet the X-ray films of the chest appear
entirely clear.

Keeping in mind that no symptom or physical sign,
including X-ray shadows, is pathognomonic, one must
determine the etiology of a demonstrable lesion, whether
it is pulmonary or extrathoracic. The fact that an indi-
vidual reacts to tuberculin does not necessarily mean that
a lesion detected in the lung is tuberculous. Tuberculin
reactors are just as likely to develop non-tuberculous
pulmonary lesions as non-reactors. To locate a gross
pulmonary lesion generally requires almost no effort, as
a single X-ray film usually suffices. To determine its
etiology may be equally simple, or it may require a tre-
mendous amount of painstaking effort, since the etio-
logical agent, whether it be malignant cells, pathogenic
bacteria and fungi, and the like, are microscopic. There-
fore, we must depend largely upon the use of the micro-
scope, culture media, and animal inoculation in determin-
ing etiology. Tuberculous lesions may already be elim-
inating tubercle bacilli when first detected. The first
microscopic inspection of sputum or gastric washings may
reveal the presence of acid-fast bacilli which, when stud-
ied in cultures and animal inoculations, may prove to be
tubercle bacilli. On the other hand, the lesion may be
only in the stage of infiltration and tubercle bacilli are
not recoverable by laboratory methods. A demonstrable
lesion may not even be tuberculous and, therefore, one
must go through the entire gamut of diagnostic pro-
cedures seeking for other organisms and sometimes re-
sorting to biopsy material obtained by the bronchoscopist.
Even with all of this, an etiological diagnosis may not be
possible immediately. A lengthy period of observation
and study may be necessary, including a series of X-ray
films, to determine how long the lesion persists and
whether it changes in size or character.

In this country more adults than children are now de-
veloping primary tuberculosis. Consequently, it is not
unusual for students or personnel to become infected
with tubercle bacilli for the first time while in school or
during employment. In 5 to 10 per cent of such persons
the primary pulmonary lesions attain a size and consis-

tency so that X-ray shadows are cast. These have pre-
cisely the same appearance as lesions of the reinfection
type. There is no possible way to differentiate between
them except when a good tuberculin testing record is
available. If the individual has become a tuberculin re-
actor within the past three or four months, in all proba-
bility the lesion, if tuberculous, is primary; on the other
hand, if it is known that the tissues have been sensitized
for a considerable period of time, the lesion belongs to
the reinfection type. Even symptoms and bacteriological
studies may not at first enable one to differentiate, inas-
much as primary lesions occasionally cause hemoptysis
and other symptoms over a brief period of time, and in
as many as 25 per cent of them tubercle bacilli may be
recovered from the sputum or gastric washings. Ac-
curate differentiation is extremely important because the
treatment is so different for the two conditions. In the
diagnosis of tuberculosis we must keep in mind con-
stantly that there are only two specific findings to be
revealed by the examination: namely, the tuberculin re-
action and the recovery of tubercle bacilli. In the absence
of the former, with well-known but unimportant excep-
tions, one is never justified in making a diagnosis of
tuberculosis in any stage of its development.

Ideal Case-Finding

During the past quarter of a century I have had the
opportunity of testing every method of case-finding that
has been proposed. Although several methods are good,
the one that has proved most efficacious in my area of
activity consists of:

1. Screening from any group under consideration
those who have the primary type of tuberculosis, regard-
less of age. This is done solely by the tuberculin test.

2. All who do not react, indicating that primary tuber-
culosis is not present on the initial testing, are retested
annually, and whenever one is found to have developed
primary tuberculosis since the previous testing, he is
added to the group of reactors from the original testing.

3. All with primary tuberculosis who have reached
adult life have X-ray film inspection of the chest imme-
diately. Those who present shadows that may be caused
by the reinfection type of pulmonary tuberculosis are
completely examined or observed so that a diagnosis can
be made at the earliest possible moment. For them ap-
propriate treatment is recommended.

4. Those who have no X-ray shadows (or only evi-
dence of calcium deposits) are scheduled for annual
X-ray inspections of their chests. It is in this group that
one actually finds the disease early, as far as it may be
disclosed by X-ray shadow. Obviously, the person with
a clear X-ray film of the cheste today, but who has defi-
nite evidence of disease at the next annual examination,
has developed gross pathology during the year. This may
be regarded as early tuberculosis but it is not necessarily
minimal. In some cases (we do not know the percentage)
moderately or even far advanced disease may appear
within a period of three or six months.

Minimal lesions found at the time of the first tuber-
culin test and X-ray film are not necessarily tuberculous,
and often those which are proved are not early. Indeed,

December, 1946

413

many of them have long since been brought under con-
trol by the defense mechanism of the body (with or
without significant illness or treatment) and are now
arrested or apparently cured. In approximately one-
fourth of the persons who develop chronic reinfection
type of pulmonary lesions, the disease comes under con-
trol with little or no treatment, and often without the
individual having any knowledge of its presence. How-
ever, many such lesions result in permanent densities
which cast X-ray shadows. Obviously, therefore, there
is an accruement of such cases in any large group of in-
dividuals following the attainment of adulthood. Con-
sequently, if one examines 100,000 apparently healthy
adults, among the lesions found there will be a prepon-
derance of this so-called minimal type. Those who have
become significantly ill from this disease have already
been removed from the group. However, in a minority
of all the lesions found the disease is moderately or far
advanced. This small percentage of individuals consists
of those who have had no symptoms, despite the extent
of the disease, or have neglected or ignored them. On
the other hand, if one examines 100,000 persons as they
are being admitted to sanatoriums there will be a pre-
ponderance (80 to 90 per cent) whose lesions are classi-
fied as moderately or far advanced. These are the per-
sons who have dropped out of work largely because
symptoms have appeared. A small number (usually not
more than 10 to 20 per cent) have minimal lesions.
These are the persons who have: (a) Been fortunate
enough to develop symptoms while the lesions are mini-
mal; (b) had the disease found when an examination
was being made for some other purpose, such as follow-
ing an accident or for insurance, or through routine
annual examination; (c) those whose lesions are not tu-
berculous or, if so, are of no clinical significance. Their
pre-admission examinations have not been adequate.
These persons probably contribute in a large way to
15 or 20 per cent of the patients admitted to our sana-
toriums who are discharged in a short time because no
indication can be found for treatment.

5. The source of infection should always be sought.
Among adults who react to tuberculin on the first testing
the source may be found with considerable difficulty or
not at all in many cases. However, among those who
have become reactors since the last annual testing, the
source is not far distant in point of time and often can
be discovered.

Schools with Special Tuberculosis Hazard

All institutions that have schools of nursing or medi-
cine either have had or still have a serious tuberculosis
problem among the students and personnel of these divi-
sions. This is because in line of duty there is contact
with contagious cases of tuberculosis who are not being
managed under strict contagious disease technic. The
problem may develop in a general hospital or in a sana-
torium; its seriousness depends upon the amount of con-
tact that is permitted with the patients. Obviously, it
is far less serious in a general hospital where there is
only the occasional case of contagious tuberculosis, even
though it is unsuspected, than on a regular tuberculosis

service in a hospital or sanatorium, where a high per-
centage of the patients has contagious disease. Boynton
studied this subject carefully and found that the tuber-
culous infection attack rate was 100 times greater among
student nurses in a general hospital than among students
in a College of Education on the same campus. How-
ever, among those students who were compelled to take
a tuberculosis service the infection attack rate was 500
times greater than in the College of Education. After
all, it makes no difference whether exposure to conta-
gious cases of tuberculosis occurs in a home, a classroom,
a general hospital or a sanatorium, as far as the indi-
vidual is concerned. The point of importance is that
it has been allowed to occur.

The tuberculosis problem in our professional schools
can be solved in large part and the solution consists of
preventing the tubercle bacilli of patients from reaching
the bodies of students who are in contact with them.
There is no excuse for a general hospital having unsus-
pected contagious cases of tuberculosis in either its out-
patient or in-patient service. Disease in this stage is so
easily diagnosed that it should be detected immediately
upon admission and before students come in contact
with the patients. Those found to have tuberculosis
should be placed under rigid contagious disease technic
immediately so that an adequate barrier between patients
and personnel is afforded. Some of our schools of nurs-
ing and medicine have teaching affiliations on special
tuberculosis services and in sanatoriums. These are ex-
ceedingly dangerous to students unless the most rigid
contagious disease technic is employed. It is my firm
conviction that without such technic students should
never be permitted to participate in the care of tubercu-
lous patients. Directors of some schools of nursing still
maintain that the standards of their schools are lowered
if contact between tuberculous patients and students is
not maintained as a part of their teaching. The price the
students pay in health and life, itself, for the next quar-
ter of a century is far too high to justify such an un-
pardonable experiment. In reality, nothing is taught on
a tuberculosis service that is not presented as well or
better on a contagious disease service. Unless a hospital
or a sanatorium is willing to adopt the most rigid con-
tagious disease technic known, its patients should be
cared for only by full-time and well-trained personnel.
Even to them the hazard of contagion should be con-
stantly emphasized, and their salaries should be commen-
surate with the risk involved.

Cooperation with Other Organizations

Health Service staffs can do much to reduce the inci-
dence of tuberculosis among students in colleges and uni-
versities by encouraging the tuberculosis control program
in the communities from which their students are de-
rived, and especially to support the nation-wide cam-
paign which has been launched in the grade and high
schools of this country. The Committee on Tuberculosis
of the American School Health Association has subcom-
mittees in each state, and in some places the members
of these subcommittees cooperate closely with similar sub-
committees of the American Academy of Pediatrics. The

414

The Journal-Lancet

objective of these subcommittees is to arrange for the
establishment of good tuberculosis control programs in
the schools of their respective states. A recent innova-
tion consists of certifying schools on the basis of tuber-
culosis control programs in progress.

It has been suggested that each state subcommittee
prepare the qualifications for certification of the schools
in its own state. In Minnesota the subcommittee has
arranged for different grades — A, B, and C — depend-
ing upon the program the schools adopt. For example,
to attain a Class A certificate at least 95 per cent of
all the children must be tested with tuberculin and the
nonreactors retested at least every other year; the tuber-
culin reactors must have X-ray inspections of their chests
during the freshman and senior years of high school.
All members of the school personnel must have the tuber-
culin test, and all non-reactors are retested every two
years. All reactors among the personnel must have X-ray
film inspection of the chest periodically. For both stu-
dents and personnel, whenever shadows are found, com-
plete examinations are required. The entire Northfield
school system received a Class A certificate in October
1945. In the sanatorium district of four counties, direct-
ed by Dr. L. S. Jordan, more than one hundred schools
have just qualified for certification. This work dovetails
so perfectly with that of Student Health Services of col-
leges and universities that the Committees on Tubercu-
losis of both organizations could work together to im-
mense advantage.

Management of Cases

On every campus there is still a considerable number
of students and personnel members who have primary
tuberculosis as manifested by the tuberculin reaction.
The X-ray films of the chest are clear, for the most part,
only a small percentage having evidence of calcium de-
posits. They require no treatment whatsoever and may
engage in all of the activities of the institution, includ-
ing athletics. However, each one should be instructed
to guard himself against exposure to contagious cases
of tuberculosis. Moreover, each one should be examined
periodically at intervals of one year if possible, always
including X-ray inspection of the chest. Among those
who enter school as reactors who recently acquired the
infection, together with the small group which becomes
infected while on the campus, only a small group (5 to
10 per cent) have primary lesions in the pulmonary par-
enchyma that are demonstrable on the X-ray film. The
majority of such individuals have no significant symp-
toms and require no active treatment. They should be
kept under close observation for lesions of the acute or
chronic reinfection type of disease. From the occasional
fresh primary lesion significant symptoms, such as tem-
perature elevation, small pulmonary hemorrhages occur,
and over a brief period tubercle bacilli are recoverable
from the sputum. The red cell sedimentation rate is
elevated. Such cases must be isolated and treated symp-
tomatically, including strict bed rest. This should be
continued until all symptoms have disappeared, includ-
ing cough and expectoration, and the sedimentation rate
has returned to the normal level. Because recovery oc-

curs so promptly in such cases (usually within two or
three months) long periods of hospitalization, sanatorium
care, or collapse therapy, are unnecessary.

When active reinfection type of tuberculosis is found
in any part of the body, appropriate treatment should
be instituted at once. For example, cases of renal tuber-
culosis and those with bone and joint lesions should im-
mediately be referred to the urologist and the ortho-
pedist. In cases of the reinfection type of pulmonary
tuberculosis which are found on the first examination,
determination of activity may require a great deal of
work and a considerable period of observation. When
first detected by the Health Service such lesions may be
in the arrested or the apparently cured stage, either with
or without previous treatment. Obviously, such cases do
not need treatment at the moment but should be kept
under close observation for reactivation of old lesions or
the appearance of new ones.

Obviously, persons who are found to have active and
contagious pulmonary tuberculosis should have treatment
instituted at once, preferably in a hospital or a sana-
torium. In some carefully selected cases, ambulatory
artificial pneumothorax, plus a well regulated life, is
permissible while the individuals continue their work on
the campus. This is especially suitable for persons who
are being periodically examined because of the presence
of a tuberculin reaction and who present lesions on a
regular examination which were not detectable at the
time of the last annual examination.

With the recent revival of chemotherapy considerable hope
has been engendered in finding a drug that will be effective in
tuberculosis. At the present moment streptomycin appears to
offer considerable promise. It has been found efficacious in ex-
perimental tuberculosis and favorable reports have been made
concerning its use in a few human cases. However, because of
the limited amount of the drug available, it has not yet been
possible to give it adequate trial in a sufficiently large number of
cases to justify final conclusions. Splendid work in progress by
Hmshaw, Feldman, Pfuetze, and others may be continued and
extended as the availability of the drug increases, so that we
may expect considerable information concerning its efficacious-
ness within the next year or two. If streptomycin or any other
drug is found to have a definite germicidal action in the human
body and can be stripped of unduly toxic effects, one would ex-
pect it to be most effective during the early development of the
primary complex. Therefore we might anticipate that Student
Health Services would administer such a drug to every tuber-
culin reactor, even in the absence of all other findings just as
we now institute treatment for syphilis in many cases with
nothing more than serological evidence.

To date we possess no immunizing agent that can be recom-
mended for use in Student Health Services. In fact, since an
attack of primary tuberculosis with virulent strains of tubercle
bacilli does not result in dependable immunity, it still appears
that attempts to immunize with such agents as BCG, is the
wrong approach to the solution of the problem. Moreover, the
Student Health Services in this country can readily solve the
tuberculosis problem by the well established and proved proce-
dures above outlined, and therefore there is no urgent need for
an immunizing agent. If all the students and personnel of a
campus were given a substance like BCG, which sensitizes the
tissues to tuberculoprotein so that all would react to tuberculin,
there would be no way to determine which individuals are in-
fected with virulent tubercle bacilli or subsequently become so,
and therefore our most valuable weapon against tuberculosis —
the tuberculin test — would be rendered useless. Although it was
first used in 1913, BCG is still in the experimental stage; to
introduce it on any campus would constitute an experiment on
the students.

December, 1946

415

The Use of Physostigmine and Neostigmine Therapy
in Neuromuscular Dysfunction Caused by Trauma

with Special Reference to the Sequelae of War Wounds

Joel Goldman, M.D.*

Lewistown, Pennsylvania
Abraham Cohen, M.D.*

Philadelphia, Pennsylvania

In 1943, H. Kabat and M. E. Knapp 1 discussed the
use of neostigmine in the treatment of poliomyelitis.
It was their belief that neostigmine, in addition to its
parasympathetic effect, relieved muscular hyperactivity
(muscle spasm) due to proprioceptive reflexes.

By inhibiting the action of cholinesterase, neostigmine
enables the accumulation of acetylcholine in concentra-
tions greater than normal. Profound physiologic changes
are thus produced throughout the body. This parasym-
pathetic effect may be nullified by the use of atropine.
The altered conditions of the synapses in the spinal cord,
following the use of neostigmine in many cases, led to
decreased skeletal muscular hyperactivity and proprio-
ceptive reflex hyperirritability. Kabat 2 suggests that, in
addition to the above, neostigmine probably facilitates
the development of new nerve pathways in the central
nervous system. If this is the case then these continue
to function even after neostigmine is discontinued.

It was to be expected that the benefits of neostigmine
could be reproduced similarly in other types of neuro-
muscular dysfunction. Kabat found the drug to be of
value in post-traumatic disability, fibrositis, chronic rheu-
matoid arthritis, bursitis, hemiplegia, cerebral palsy,
facial paralysis, etc. Trommer and Cohen 3 reported
similar results in a series of cases of rheumatoid arthritis.
Bell and Boone 4 reported the successful treatment of
muscle spasm in a case of arachnidism by the use of
neostigmine methylsulfate. Cohen, Trommer and Gold-
man 5 have successfully treated a large number of cases
of rheumatoid arthritis substituting physostigmine salicyl-
ate and atropine sulfate for neostigmine and atropine.
They found little difference in the action of the two
drugs, with the exception that fewer side effects were
noted when physostigmine salicylate was used.

During the last two years there have been many cases
of neuromuscular dysfunction seen as a result of civilian
and military accidents and wounds. The great industrial
effort of World War II carried with it numerous civilian
casualties. The wounded of the battlefields are seen
daily. The economic, social and crippling effect of such
accidents and wounds cannot be exaggerated. In the
past little could be done for many such cases, for physio-
therapy and orthopedic surgery were successful in a dis-
tinctly limited number.

The authors, in reporting the following cases of treat-

*From the Arthritis Clinic of the Philadelphia General
Hospital.

ment of neuromuscular dysfunction due to industrial
and battle wounds, feel that the work of Kabat 2 has
great merit. In another paper,5 the use of physostigmine
interchangeably with neostigmine is described. Physo-
stigmine was selected since it was pharmacologically simi-
lar to prostigmine, cheaper as to cost, and presented
fewer side effects. Both were combined with suitable
quantities of atropine sulfate to reduce or eliminate un-
desirable parasympathetic side effects. The drug was not
given by mouth, since our experience with neostigmine
bromide administered orally in treating rheumatoid
arthritis was disappointing.5 It was found that benefits
were obtained by hypodermic injections only.f Cases
were started on a placebo to observe whether or not any
degree of improvement occurred merely by the initiation
of a new form of therapy. It is to be stressed that many
of these patients have traveled from physician to physi-
cian seeking relief and any unusual interest in their re-
covery by a physician may have led to emotional factors
giving a false sense of improvement and even recovery.
Once basic conditions were established, neostigmine or
physostigmine with atropine were used.

Procedure

The drug, physostigmine or neostigmine, was injected
daily subcutaneously in the following doses:

1. Physostigmine Salicylate (Eserine Salicylate) gr.
1/100 (0.65 mg.) with Atropine Sulfate, gr. 1/150
(0.4 mg.)

2. 2 cc. Neostigmine Methyl Sulfate 1:2000 solution
(1 mg.) with Atropine Sulfate, gr. 1/100 (0.65 mg.)

In most cases the drugs were given daily. No serious
side effects were noted, but it was noted that some of
the unpleasant reactions were due to excessive atropiniza-
tion. When several doses of the drug are given daily,
it is desirable to hospitalize the patients, but nearly all
cases can be treated as out-patients or as private cases
in the physician’s office. The benefits obtained from the
above have been maintained after therapy was discon-
tinued.

The return of the injured to work and self-support,
and of the wounded to a useful way of life has been
gratifying. The despondency of many veterans unable
to return to their former routine has been replaced by
a mental attitude of happiness, encouragement and faith
in the future.

"[Hypodermic Tablets, physostigmine salicylate, 0.65 mg. and
atropine sulphate, 0.4 mg. were supplied by the Endo Products
Co., Inc., for this investigation.

416

The Journal-Lancet

It must be stressed that adequate dosage of neostig-
mine or physostigmine must be used to obtain the de-
sired results. The dose of physostigmine must be gauged
by the needs of the patient. Some patients require more
than others to produce a similar effect. It is wise to
begin with physostigmine salicylate 1/100 gr. (0.65 mg.)
and atropine sulfate 1/150 gr. (0.4 mg.). Should a
reasonable amount of relaxation of muscle spasm be en-
countered, a continuation of this dosage is desirable;
however, in the event that the patient does not receive
adequate relief it may be necessary to increase the
amount of physostigmine to gr. 1/50 (1.3 mg.) with
atropine sulfate gr. 1/100 (0.65 mg.). Under these
conditions one frequently notes untoward reactions due
to either atropine or physostigmine. One must be famil-
iar with the signs and symptoms of over-dosage of each
of these drugs. Nausea, dizziness or pain in the ab-
domen are indications of excessive physostigmine or neo-
stigmine. Sometimes diarrhea becomes manifest rather
suddenly. On the other hand, if the patient complains
of excessive dryness of the throat and blurring of vision,
one is to suspect atropinization.

In the event that atropinization occurs it may be neces-
sary to reduce the quantity of atropine and perhaps in-
crease the dose of physostigmine or neostigmine to keep
the drugs in proper balance. On the other hand, if
muscle spasm is relieved, but the patient complains of
dizziness, salivation or pain in the abdomen with nausea,
the dose of physostigmine must now be decreased to
perhaps gr. 1/100 (0.65 mg.). In this way one can
arrive at a reasonable and adequate dosage for each indi-
vidual patient.

Cases of Neuromuscular Dysfunction Due to
Trauma Caused by Surgery

Case 1. I. A., white female, age 45. Chief Complaint:
Protrusion of tongue to left, impaired speech and diffi-
culty in swallowing. Duration: One month.

A mass was noted in the left anterior cervical region,
in November, 1943. Patient was seen by a reputable
radiologist who recommended biopsy. This was done on
December 18, 1943, and the tissue studies were conclu-
sive for a diagnosis of a tuberculous adenitis. The entire
gland was enucleated on April 18, 1944. On the pa-
tient’s return home from the hospital, it was noted that
her tongue protruded to the left, she had difficulty in
swallowing, and her speech was indistinct. Apparently
this was caused by injury to the innervation of the
tongue by the surgical procedure. On June 1, 1944, the
patient was placed on a daily dosage of neostigmine
1.0 mg. and atropine sulfate 0.65 mg. Her improve-
ment was prompt and very encouraging. In a few weeks
the tongue protruded in the mid-line, speech cleared,
and the swallowing function returned to normal. On
July 1, 1944, treatment was changed to daily doses of
physostigmine salicylate 0.65 mg. and atropine sulfate
0.40 mg. The improvement continued and all treatment
was stopped August 1, 1944. There has been no re-
currence.

Case 2. S. D., white, male, age 38. Chief Complaint:
Painful fixation of the left knee. Duration: Two years.

Two years ago, while at work, the patient twisted his
left knee. He was told that he had dislocated cartilages
in this knee and that they would have to be removed
surgically. The left knee joint was opened and menisec-
tomy was performed on April 1, 1944. The wound and
joint became infected resulting in a deformity of the
left knee. It was painful, flexed and fixed with consid-
erable spasticity of the hamstring muscles. A brace was
worn until November 3, 1944, when daily subcutaneous
injections of neostigmine methyl sulfate 2 cc., 1/2000
(1 mg.) and atropine sulfate 1/100 (0.65 mg.) were
started. At the end of several days the muscle spasm
which had fixed the left knee in angulation relaxed suf-
ficiently so that his left foot could be firmly and com-
pletely placed on the floor. The brace was discarded.
Although this patient has slight recurrence of muscle
spasm in damp weather, the condition has never returned
to its former state and he is able to earn his living as
an electrician. The neostigmine 1.0 mg. and atropine
sulfate 0.65 mg. were injected subcutaneously daily
from November 3, 1944, until February 1, 1945. Since
that time physostigmine salicylate 0.65 mg. and atropine
sulfate 0.65 mg. were given daily as above for an addi-
tional month: no change in the rate of progress could
be noted when using the physostigmine. The improve-
ment has been gradual and continuous and all therapy
was discontinued on March 1, 1945.

Cases of Neuromuscular Dysfunction Due to
Trauma Caused by Industrial Accidents

Case 3. A. H., white, male, age 59. Chief Complaint:
Spastic, fixed left knee. Duration: Five months.

In August, 1942, a 20-pound wrench falling a dis-
tance of about 30 feet struck the patient’s left knee.
He sustained a broken cartilage and menisectomy was
found necessary. Following the operation, the knee did
not return to normal. It was painful and semi-fixed in
flexion. The patient walked with a marked limp. A
brace was used as a support and he was unable to be
on his feet for a very long period of time. Physical ex-
amination revealed the hamstring muscles definitely spas-
tic and the knee was held in a fixed, semi-flexed position.
Beginning December 2, 1944, neostigmine methyl sulfate
1.0 mg. and atropine sulfate 0.65 mg. were given hypo-
dermically daily. On December 11, 1944, the leg was
relaxed, stable and supported the patient well. The
brace was no longer necessary. Since there was a ten-
dency for the muscles of the affected leg to resume their
spastic state, neostigmine and atropine therapy was con-
tinued until May 14, 1945. Physostigmine salicylate
0.65 mg. and atropine sulfate 0.65 mg. were given daily
for an additional month. All treatments were stopped
June 15, 1945, since it was felt that a maximum benefit
had been achieved. He has approximately 75 per cent
function of the left knee, and the patient has returned
to his work as a machinist in a steel mill. To date there
has been no regression.

Case 4. F. C., white, male, age 48. Chief Complaint:
Low back pain, staggering gait, pains in thighs, back
and asymmetry of face. Duration: Two years.

Two years ago while at work as a mechanic, a heavy
wire perforated the patient’s right ear drum, injuring

December, 1946

417

the cocchlea. His face became drawn to the left; the
right side of his mouth dropped; his right lower lid
became ptotic. Because of a staggering gait, the muscle
groups of his back became spastic. He had pains in his
lumbar and shoulder girdle areas. On July 1, 1944, a
daily schedule of neostigmine methyl sulfate 1.0 mg.
and atropine sulfate 0.65 mg. was started. Relaxation of
muscle spasm resulted, thus producing considerable re-
lief from pain in the back. There was no change in the
underlying condition, but the patient was practically free
from pain during the use of the above medication. Phys-
ostigmine was not used in this case. The results were
entirely subjective. The treatment lasted for six weeks.
Upon discontinuing the medication, there was a return
of spasm of the spinal muscles and some recurrence of
back pain.

Case 5. A. K., age 41, female. Chief Complaint:
Back strain with associated sciatica. Pain in the lower
back radiating down the right leg to the heel and down
the left leg to the popliteal space. Duration: Present
illness dates back about six weeks when the patient sud-
denly, while lifting a heavy object, felt something "give”
in the lower back. This was accompanied by severe pain
in the back radiating down the right leg to the heel and
the left leg to the popliteal space. The pain became so
intense that the patient was unable to get around. Even
in the recumbent position there was no relief from dis-
comfort. Morphine was necessary for relief. She states
that as long as she received the injections she was able
to sleep and was not conscious of pain, however, she
always had discomfort during her waking hours. Oral
medication seemed to be of no avail. The patient had
been seen every other day by her physician and at each
visit an "injection” was necessary.

Physical examination. Physical examination revealed
a female, 41 years of age, who complained of severe
pain in the lower back radiating down the legs. Head
and neck were negative, as were the chest and abdomen.
In the back one could elicit tenderness over both sacro-
iliac joints. Coughing or sneezing did not aggravate her
discomfort. There was also tenderness over the sciatic
nerve of both legs. While standing there was a decided
deformity of the right hip. The muscles of the lower
back were in spasm. They were tense but not tender.
Flexing the thigh on the abdomen and attempting to
extend the leg caused excruciating pain. (Leseque’s
sign) .

Treatment. September 15, 1945, hypodermic injection
of physostigmine salicylate 1/100 gr. (0.65 mg.) with
atropine sulfate gr. 1/150 (.4 mg.) were administered
simultaneously. In ten minutes the patient felt consid-
erable relief from the discomfort and desired to get out
of bed. This treatment was repeated daily for a period
of about ten days. At the end of this period, the patient
was free from pain and has been getting along fairly
well ever since. She was sent to a radiologist for diag-
nostic X-ray examination. His report is as follows:

"Minimal arthritic changes of the sacro-iliac joints.
Postural acute angulation of the lumbo-sacral arc. This
may be significant in accentuating the symptomatology

in this instance.” To date the patient has had no recur-
rence of symptoms.

Cases of Neuromuscular Dysfunction Due to
Trauma Caused by Projectiles or
Military Accidents

Case 6. A. B., white, male, age 38. Chief Complaint:
Nearly useless, wounded right arm. Duration: Six
months.

This patient was seen on December 19, 1945. Due
to the effects of wounds caused by shrapnel, his right
arm was practically useless. He was wounded at St. Lo
in Normandy on July 11, 1944. There were nearly one-
half dozen wounds in the right arm between the shoulder
and wrist. The right brachial nerve had been severed
and spliced. The right shoulder, elbow and wrist were
semi-fixed and muscles were in spasm. The fingers of
his right hand could not touch the right thumb when
an attempt was made to close the hand to form a fist.
The loss of function was 90 per cent at the shoulder,
75 per cent at the elbow and 100 per cent at the wrist.
On December 19, 1945, daily subcutaneous injections of
neostigmine methyl sulfate 1.0 mg. and atropine sulfate
0.65 mg. were started. As the muscle spasm relaxed, the
fixations at the shoulder, elbow and wrist became mobile.
The digits of the right hand relaxed and a fist could be
made on flexion of the fingers; the fist could be closed
and opened at will. The daily injections were continued
for one month, when physostigmine salicylate 0.65 mg.
with atropine sulfate 0.65 mg. were substituted for the
original drugs. The improvement continued but progress
was slow. Two months after treatment was started the
right arm was once more a useful member with approxi-
mately 80 per cent normal function at the shoulder, 50
per cent at the elbow and 80 per cent at the wrist.
There were no untoward reactions.

Case 7. M. D., white, male, 65 years of age. Chief
Complaint: Partially paralyzed right hand. Duration:
Four years.

Four years ago this patient was shot in the right arm,
the bullet severing the right brachial nerve. The nerve
was spliced by a neuro-surgeon. The hand was useless
due to nearly 100 per cent loss of function at the wrist
and 80 per cent loss of function of the fingers. On
November 14, 1944, the use of daily doses of neostig-
mine methyle sulfate 1.0 mg. and atropine sulfate 0.65
mg. was started. At the end of two months physostig-
mine salicylate 0.65 mg. and atropine sulfate 0.65 mg.
were substituted. There was a 20 per cent return of
function in the use of his hand at the wrist and fingers.
The patient can now hold his service revolver with his
right hand and feels a gradual return of power.

Case 8. F. S., white, male, age 33. Chief complaint:
Staggering gait, difficulty in controlling urinary bladder
and bowels. Duration: Six months.

This patient, while leading a patrol in Germany on
March 23, 1945, was struck in the back by a high
velocity anti-tank shell. A wound 20 cm. in length
crossed the vertebral column at the level of the twelfth
dorsal vertebra. He was hospitalized for four months
in Europe because of total paralysis from the waist down.
Within three months he could only partially control his

418

The Journal-Lancet

bowels and bladder. When seen September 6, 1945, he
had a shuffling gait, was unsteady on his feet, had diffi-
culty in controlling his bowels and bladder and was de-
pressed mentally. On September 6, 1945, daily sub-
cutaneous injections of neostigmine 1.0 mg. and atro-
pine sulfate 0.65 mg. were begun. A most remarkable
change occurred; almost immediately his walking im-
proved, he became stronger and within one month he
had improved to such an extent that he returned to
work. Physostigmine salicylate 0.65 mg. and atropine
sulfate 0.65 mg. were substituted for neostigmine and
atropine and improvement was maintained. There re-
mains an element of foot drop, but 90 per cent normal
function in his legs has persisted. The bowel and blad-
der functions are 100 per cent normal.

Case 9. P. F., white, male, age 36. Chief Complaint:
Severe pain in left shoulder and upper back. Duration:
Six months.

Eighteen months ago, during a severe storm at sea,
the patient was thrown against a bulkhead. He sus-
tained an injury to the left shoulder and dorsal spine
area causing severe pain in these regions. He was hos-
pitalized for several months. His tonsils were removed
as a general health measure. When seen on December
27, 1944, he had severe pain in the left shoulder and in
the dorsal spinal region. The muscles of these areas
were spastic. There was a loss of function of at least
50 per cent on ordinary effort. On January 1, 1945,
daily dosages of physostigmine salicylate 0.65 mg. and

atropine sulfate 0.65 mg. were started. The spasticity
slowly relaxed and the pain gradually disappeared. All
studies were negative with the exception of the X-ray
films. These showed "evidence of narrowing of the
bodies of the fifth and sixth cervical vertebrae; there was
no disease of the vertebra and the changes are probably
traumatic in origin.” Treatment was continued for
three months and return of function was 100 per cent.
The patient now earns his living as a truck driver.

Summary and Conclusions

1. Physostigmine and atropine combination is sug-
gested for use in the treatment of muscle spasm due to
trauma caused by surgery, industrial accidents, war
wounds and back sprain.

2. Nine cases are herein described in detail.

3. Treatment is simple and uncomplicated and there-
fore can be carried out in the physician’s office on am-
bulatory cases.

Bibliography

1. Kabat, H., and Knapp, M. E.: The Use of Prostigmine
in the Treatment of Poliomyelitis. J.A.M.A., 122:989, 1943.

2. Kabat, H.: Studies on Neuromuscular Dysfunction. Pub-
lic Health Reports, 59, No. 51 (Dec. 22), 1944.

3. Trommer, P. R., and Cohen, A.: The Use of Neostig-
mine in the Treatment of Muscle Spasm in Rheumatoid Ar-
thritis and Associated Conditions. Preliminary report. J.A.M.A.,
124: 1237, 1944.

4. Bell, J. E., Jr., and Boone, J. A.: Arachnidism Treated
by Neostigmine Methylsulfate. J.A.M.A., 129: 15, 1016.

5. Cohen, A.; Trommer, P. R.; and Goldman, J.: Physo-
stigmine for Muscle Spasm in Rheumatoid Arthritis and Allied
Conditions. In press.

TUBERCULOSIS RESEARCH PROGRAM

Guided by recommendations of a conference of out-
standing leaders in tuberculosis from the United States,
China, and Denmark, the United States Public Health
Service, Federal Security Agency, will extend its tuber-
culosis research program to include studies on the effec-
tiveness of BCG vaccine in preventing this disease, Sur-
geon General Thomas Parran announced.

At the conference, Dr. Herman E. Hilleboe, Chief,
Tuberculosis Control Division of the Public Health
Service, reviewed the past experience with BCG, named
bacillus of Calmette and Guerin for the French scientists
who discovered it. Dr. Hilleboe pointed out that the
vaccine has been extensively used in Europe and South
America in artificial immunization against tuberculosis
and that research on this subject has been undertaken in
the United States by competent investigators. — (U. S.
Public Health Service Release.)

100 YEARS AGO

One hundred years ago New York City had 30 deaths
from tuberculosis during a single August week. Accord-
ing to Herald T ribune, the disease ran a close second to
cholera infantum. Other deaths during the week were
attributed to apoplexy, sunstroke, "inflammation of the
bowels,” diarrhea, dysentery, and "dropsy in the head.”

T-B GERM PERILS ESKIMO POPULATION

The natives of Alaska face extermination by tubercu-
losis unless vigorous corrective measures are taken, ac-
cording to Army and Red Cross officials. Some 40 per
cent of the natives have the disease, and in isolated vil-
lages the percentage is higher.

Why Eskimo children have a low resistance is evident
in their diet which consists of bread, fried dough, and
store candy, with only rare tastes of meat. The result,
according to the Alaska Native Service, is that their
teeth are often inferior to those of their parents, who
looked upon fish-eye chowder, seaweed, and berries cov-
ered with seal oil as delicacies.

In Alaska the proportions of hospitals to residents is
one to every 90. Until this spring there was no ortho-
pedic clinic in the territory, and there still is no program
for the care of the blind.

Three Army hospitals have recently been acquired by
the Department of Public Health which will treat tuber-
culosis, and plans are in the making for a hospital near
Anchorage which will be built from surplus Army huts
and supported by the American Red Cross and local
agencies. — (Hospital Topics, October, 1946.)

December, 1946

419

Remarks for Variety Club Heart Hospital Dinner

By H. S. Diehl, M.D., Dean Medical Services, University of Minnesota
Minneapolis, Minnesota

This talk was given at the presentation of the Variety Club Heart Hospital to the University of
Minnesota on September 23, 1946, at which event Mr. Fred Allen of radio fame was master of Cere-
monies. The Variety Club Heart Hospital Fund, in excess of $250,000, raised by a campaign for gifts
conducted by the Variety Club of the Northwest, was presented to President J. L. Morrill of the Uni-
versity of Minnesota by Mr. A. W. Anderson, Chief Barker of the Club, who also announced the Club’s
pledge of $25,000 a year towards support of the Heart Hospital. Other speakers were the Hon.

Hubert H. Humphrey, Mayor of Minneapolis, the Hon. Edward ]. Thye, Governor of Minnesota, and
Mr. William McCraw, Executive Director of the National Variety Clubs.

Participation in a program such as this one is a new
experience for me. In the first place, cleans don’t
often make Fred Allen’s program. As I understand it,
Mr. Allen’s, famous "Alley” contains many notable char-
acters; even including a senator. Perhaps our good friend
Governor Thye can qualify after we send him to the
U. S. Senate. But never, so far as I know, has a dean
or a college professor succeeded in gaining admission to
this exclusive residential development.

In the second place, it is rare indeed that the Medical
School has the privilege of accepting a gift of such im-
portance as the one which the Variety Club is presenting
here this evening.

The real beginning of this Heart Hospital goes back
a considerable number of years when Dr. M. J. Shapiro
practically single-handed started a clinic for the Minne-
apolis school children with heart disease. This clinic was
located in the building known as the Lymanhurst School
on Chicago Avenue. There was no ballyhoo or publicity
about this work but over the years Dr. Shapiro’s clinic
rendered vital medical service to hundreds of Minne-
apolis children who were victims of heart disease.

The next chapter in this story came several years ago
when the Lymanhurst School building was turned over
to the Kenny Institute, and Dr. Shapiro’s heart clinic
had to look for another place in which to carry on. Tem-
porary arrangements of various kinds were made but
none of these was satisfactory. Then a little more than
a year ago Dr. Shapiro happened to talk about his diffi-
culties, his disappointments and his hopes for this clinic
with the late Mr. A1 Steffes, who at the time was Chief
Barker of the Variety Club. Mr. Steffes replied that
this sounded like the sort of service project in which the
Variety Club might be able to help.

Dr. Shapiro’s talks with Mr. Steffes were followed by
conferences between the representatives of the Variety
Club, the Medical School and the University adminis-
tration. These conferences were especially interesting to
me because the officials of the Variety Club had no idea
at the beginning, of undertaking a project of such mag-
nitude as this turned out to be. Yet every constructive
suggestion which was made concerning the hospital was
met by the response "of course, we’ll do it.”

By a tragic stroke of fate Mr. Steffes passed away
from an attack of heart disease several months ago. I
am sure that we are all keenly disappointed that he is
not present here this evening to take pride in the success
of the project which he inaugurated. Mr. Steffes’ term
of office as Chief Barker of the Variety Club expired

when the preliminary planning of the Heart Hospital
had been completed and Mr. Art Anderson took over.
To his deep interest, his devotion and his unceasing
efforts belongs most of the credit for the success of this
enterprise. I want to take this opportunity to tell Mr.
Anderson that we are deeply appreciative of all that he
has done for this Heart Hospital program.

The importance of this Variety Club Heart Hospital
can hardly be overestimated. We know that it will pro-
vide the best of medical service for thousands of children
and adults with heart disease. With prompt and efficient
medical care the lives of many victims of this disease can
be prolonged and even more can be returned to useful
and happy lives instead of being condemned to years of
invalidism. That alone would justify the construction
and continued support of this hospital.

But even more important is the opportunity which this
hospital will present for the study of this disease which
ranks first as a cause of death in this country. Among
children the major cause of heart disease is rheumatic
fever. This disease which transcends in importance all
the other diseases of childhood was also the foremost
medical problem of the armed forces during the early
years of the war. Tens of thousands of young men who
were afflicted with this disease, not only were rendered
unfit for military service but were discharged from the
Army or Navy with damaged hearts which will handicap
them throughout life and on the average will shorten
their life expectancy by approximately twenty years.

In order to be a bit more specific about the importance of
heart disease may I introduce just three figures.

First, in the current epidemic of infantile paralysis which is
the worst that this area has ever known 167 residents of Minne-
sota have died from this disease.

I would ask that you keep this figure in mind while I tell
you that in recent years Minnesota has been having more than
500 deaths annually from rheumatic heart disease and over
8000 deaths from all types of heart disease.

I mention this comparison not to minimize the importance or
the tragedy of infantile paralysis. No one who has had anything
to do with the epidemic could possibly do that. But I do want
to point out how much more of a problem heart disease consti-
tutes, not occasionally, but regularly year after year.

This new hospital will make it possible for our medical fac-
ulty to conduct intensive studies of the treatment, and better
still, the prevention of this disease. Funds for the support of
such research I am sure will be available as soon as we have the
facilities which this hospital will provide.

A similar intensive attack will be made upon the heart disease
of later life. I could predict with assurance that at least one out
of every three persons in this room this evening will eventually
be a victim of this disease. But even knowing that, there is little
that can be done to prevent it. Any contribution to the solution
or even a significant forward step in the control of a disease of
such importance will be of inestimable value.

420

The Journal-Lancet

AMERICAN STUDENT HEALTH ASSOCIATION NEWS LETTER

F. A. Woll, M.D., of the City College of New York,
New York, New York, has retired as Director of Stu-
dent Health and has been replaced by Frank S. Lloyd,
M.D., Chairman of the Department of Hygiene.

Margherita Ciaramelli, M.D., of New York City
has recently been appointed as Assistant Physician on the
Carleton College Health Service staff at Northfield,
Minnesota.

Murray Wagner, M.D., has been appointed the first
full time physician of the recently reorganized Student
Health Service at Union College, Schenectady, New
York.

Thomas Urmy, M.D., of Boston, recently a Major
in the Army, has been appointed as the new Director of
Student Health at Williams College, Williamstown,
Massachusetts.

Elizabeth L. Broyles, M.D., has been appointed resi-
dent physician at Wellesley College, Wellesley, Massa-
chusetts, to take the place of the late Doctor Mary
Fisher DeKruif.

Dana L. Farnsworth, M.D., Director of the Depart-
ment of Health at Williams College, has resigned to
take a position as Medical Director at the Massachusetts
Institute of Technology.

Wesley P. Cushman, M.D., has resigned from his
position as Director of Student Health at State Teachers
College, Mankato, Minnesota, to take a position in the
Physical Education Department at Ohio State Univer-
sity, Columbus, Ohio.

George Houck, M.D., has been appointed successor
to Charles E. Shepard, M.D., as Director of the Stu-
dent Health Service at Stanford University, California.
Doctor Shepard is still convalescing from a recent illness.

Ralph I. Canuteson, M.D., reports that he is estab-
lishing a complete visiting nurse service at Sunflower
Village, which is a residence district for students living
about twelve miles from the campus of the University.
In addition he is planning to set hospital facilities there
in the event of any epidemic. The enrollment at the
University is about twice that of any previous years.

George M. Decherd, Jr., M.D., has been appointed
Director of the Student Health Service at the Univer-
sity of Texas, Austin, Texas.

Robert B. Beech, M.D., is assuming the position of
acting Director of the Student Health Service at North-
western University to take the place of Richard H.
Young, who is now Dean of the University of Utah
Medical School.

Dan G. Stine, M.D., Director of the Student Health
Service at the University of Missouri, Columbia, Mis-
souri, writes the following paragraph concerning the bar-
racks, trailers, etc., on his campus:

"At present, we have a number of G.I. Villages made
up of barracks, trailers, etc., scattered over our golf links
and Agricultural College farms, each with its mayor and
town council and each with a health committee. I have
one of the physicians of the Student Health Service
assigned as Health Inspector of these villages, and one

of our women physicians acts as counselor to the wives
of the students in these villages, advising them about the
problem of wifehood and motherhood as well as the sani-
tation of the inside of the trailer or barracks apartment.
I have a feeling that one of the greatest things that will
come out of this crisis in college education will be the
training of the student in citizenship, as he assumes the
civic responsibility in his village.”

The Dean of Medicine at the University of Wiscon-
sin Medical School, Dr. Wm. S. Middleton, has an-
nounced the appointment of Dr. C. Knight Aldrich as
Assistant Professor of Neuropsychiatry in The Depart-
ment of Student Health.

Dr. Aldrich was granted the degree of Doctor of
Medicine by Northwestern University in 1939, follow-
ing which he served an internship at the Cook County
Hospital in Chicago. Later he was resident physician in
Neuropsychiatry at the United States Marine Hospital
at Ellis Island and then became associated with the
United States Public Health Service, Lexington, Ken-
tucky, and Ft. Worth, Texas. Dr. Aldrich spent a year
in the Pacific with the Coast Guard connected with the
United States Public Health Service. His home was
Winnetka, Illinois.

Announcement of the appointment of Dr. John Welch
Brown to the Professorship of Preventive Medicine and
as Director of the Department of Student Health at
the University of Wisconsin was made by Dr. Wm. S.
Middleton, Dean of Medicine at that institution. Dr.
Brown’s appointment became effective on November 1,
1946. He holds the degrees of Bachelor of Arts and
Doctor of Medicine from the University of California
and he received the M.D. degree in 1935. He was on
war leave from the University of California from No-
vember 1941 to December 1945.

Dr. Brown has held numerous important appoint-
ments, included among which were Director of Clinical
Laboratories, University of California Hospital, Assist-
ant Professor of Medicine, University of California
Medical School, Member of the Commission on Influ-
enza of the National Research Council, Army Epidemeo-
logical Board, Consultant in Medicine, Letterman Gen-
eral Hospital, U. S. Army, San Francisco, and Assistant
Visiting Physician, San Francisco Hospital, from 1939
to the time of his appointment at the LJniversity of
Wisconsin Medical School.

His publications have been extensive covering the field
of Preventive Medicine, Blood, the Pneumococcus, Im-
munology and certain of the Virus diseases including
Influenza.

Dr. Brown will utilize the Student Health Service as
a demonstration unit for closer correlation of clinical
practices with Preventive Medicine in the broader field
of Public Health. It is particularly significant that the
University of California organized the first of the im-
portant Health Services for University students in this

December, 1946

421

country in 1909, and the University of Wisconsin fol-
lowed closely in 1910 when the Health Service was estab-
lished with Dr. J. S. Evans as its Director.

Dr. Brown was horn in Iowa in 1911 and is certified
by the American Board of Internal Medicine.

Notice of the appointment of Dr. Carol M. Rice to
the Medical faculty and the Department of Student
Health at the University of Wisconsin was announced
by the Dean of Medicine, Dr. William S. Middleton,
on September 1, 1946.

Dr. Rice returns to the University of Wisconsin Med-
ical School after an absence of several years. During
that period she has been Director of the Health Service

Hook JUvUm

Diseases of the Skin, by George Clinton Andrews, 3rd
edition. Philadelphia: W. B. Saunders Co., 1946. Pp. 886,
illustrated. $10.00.

This book is a distinct improvement over previous editions.
Noteworthy is the clearness of the histopathologic illustrations
and their descriptions. The present concept of treatment of
various types of syphilis with penicillin is outlined. The chap-
ter on tropical diseases of the skin is complete yet concise and
to the point. X-ray and radium therapy and X-ray physics are
well dealt with. However, what recommends this volume highly
are the numerous well chosen and intensely representative clin-
ical illustrations. The subject matter is brief and to the point
and contains a wealth of information of both diagnostic as
well as therapeutic nature. This book is recommended for
practitioners and students, and is a worthy addition to the
American scene of dermatologic training. L. W.

The Biochemistry of Malignant Tumors, by Kurt Stern,
M.D., and Robert Willheim, M.D. Brooklyn, N. Y.:
Chemical Publishing Co., Inc. 885 pages. $12.00.

This treatise describes the relationship of cancer to chemistry
in the broadest medium of both words. In it, Kurt Stern, for-
merly research Associate of the University of Vienna, and
now of New York, and Robert Willheim, professor in the Uni-
versity of Philippines, have collaborated in an exhaustive review
of the literature and compilation of the world literature. The
present edition appears to be a reprint of the original book first
available in 1943 which was reviewed in Journal-Lancet. Main
emphasis has been placed on the literature of the past 25 years
which reflects the greatest strides in biochemical cancer research.
It is a valuable reference book for the investigator interested in
cancer, or for the clinician desiring basic information in the
subject. H. W.

Narcotics and Drug Addiction, by Erich Hesse, M.D.
New York: Philosophical Library, 1946, 219 pages, $3.75.

This book is a translation into English, and therefore a good
share of the statistics do not refer to this country. Apparently
this volume has been written for the general public and is an
attempt to stimulate interest in the overuse and abuse of the
various narcotics and stimulants. Many sections of this book,
however, are too technical for the general public to understand.
On the other hand, most of the information contained is too
simplified for the medical profession. A great deal of the con-
tents are of historical and educational interest and present a
brief, simplified review of the various drugs in spite of the
author’s attitude and dogmatism against the use of these drugs
in any form. A. B. B.

at Sweet Briar College in Virginia.

She holds the Bachelor of Arts degree from Smith
College and a Masters degree from Wellesley. Dr. Rice
was granted the degree of Doctor of Medicine by the
University of Wisconsin in 1931. She served an intern-
ship at the State of Wisconsin General Hospital as well
as a residency in Medicine and Neuropsychiatry at that
same institution. In addition, she has done graduate
work in Vienna.

Dr. Rice now holds the appointment of Associate
Professor of Clinical Medicine, and Assistant Director
of the Student Health Service at the University of
Wisconsin.

Peripheral Vascular Diseases, by Edgar V. Allen, Nelson

W. Barker, Edgar A. Hines. Philadelphia: W. B. Saun-
ders Company, 1946. 871 pages. $10.00.

This book represents the experience of the last twenty-five
years of the Mayo Clinic with peripheral vascular diseases.
Besides the authors there are eleven contributors, all Mayo staff
members. The work is profusely and beautifully illustrated.
Many of the chapters are prefaced with a portrait and thumb-
nail sketch of one of the men who discovered or popularized
one of the vascular diseases. The preclinical chapters — defini-
tions, vascular anatomy, methods of investigation — are an ex-
cellent introduction to the study of peripheral vascular disease.
The clinical sections are masterfully done and testify to the tre-
mendous experience in the field by these authors. This reviewer
considers this text to be the best in the field, required reading
for anyone interested in vascular pathology. R. B.

. . . IHEET OUR (MRIBUTORS . . .

Dr. Robert O. Quello has practiced in Minneapolis for
the past ten years, and is a member of the Swedish Hos-
pital staff. He was graduated from the University of
Minnesota in 19.36, M.D. degree. He is a member of the
Hennepin County Medical Society, the Minnesota State
Medical Association, and the A M. A.

Dr. O. Theron Clagett, who specializes in thoracic sur-
gery, has been on the surgical staff of the Mayo Ciinic,
Rochester, Minnesota, since 1940. He was graduated from
the University of Colorado Medical Schoo 1, class of 1933,
with the degrees of M.D., M.S., and F.A.C.S., with grad-
uate work at the Mayo Foundation from 1935 to 1940.
He is a member of the A M. A., American Society for
Thoracic Surgery (active member), Central Surgical As-
sociation, Minnesota Trudeau Society, and the American
Trudeau Society. He was also elected as honorary mem-
ber of the Mexican National Academy of Surgery this
year.

Dr. J. Arthur Myers of Minneapolis is nationally
known for his work in the field of tuberculosis.

Dr. Joel Goldman, Lewiston, Pennsylvania, is Assist-
ant Chief of the Arthritis Clinic, Philadelphia General
Hospital. In 1931 he was graduated from Jefferson Med-
ical College, M.D. degree. He specializes in internal med-
icine and is a member of the A.M.A., the Mifflin County
of Pennsylvania Medical Society, and the Pennsylvania
State Medical Society.

Dr. Abraham Cohen, Philadelphia, Pennsylvania, is
Chief of the Arthritis Clinic and Associate in Medicine,
Philadelphia General Hospital. His specialty is internal
medicine with special reference to arthritis and its allied
diseases. He was graduated from Jefferson Medical Col-
lege in 1925, M.D. degree. He is a member of the
A.M.A., the Pennsylvania County Medical Society, In-
ternational Rheumatism Association, Brussels, Belgium,
and the International Society of Medical Hydrology,
London, England.

Serves the %. Medical Profession of

MINNESOTA, NORTH DAKOTA, SOUTH DAKOTA and MONTANA

ADVISORY COUNCIL

North Dakota State Medical Assn.
Dr. A. E. Spear, Pres.

Dr. Philip G. Arzt, Pres.-Elect
Dr. L. W. Larson, Secy.

Dr. W. W. Wood, Treas.

North Dakota Society of
Obstetrics and Gynecology
Dr. Paul Freise, Pres.

Dr. G. Wilson Hunter, Vice Pres.
Dr. F. A. DeCesare, Secy.-T reas.

Minneapolis Academy of Medicine
Dr. Russell W. Morse, Pres.

Dr. Paul F. Dwan, Vice Pres.

Dr. J. C. Miller, Secy.

Dr. Ragnvald S. Ylvisaker, Treas.
Dr. Henry E. Hoffert, Recorder

South Dakota State Medical Assn.
Dr. F. S. Howe, Pres.

Dr. H. R. Brown, Pres.-Elect
Dr. J. L. Calene, Vice Pres.

Dr. Roland G. Mayer, Secy .-Treas.

South Dakota Public Health Assn.
Dr. J. M. Butler, Pres.

Dr. C. E. Sherwood, Vice Pres.

Dr. Gilbert Cottam, Secy.-T reas.

Sioux Valley Medical Assn.

Dr. D. S. Baughman, Pres.

Dr. Will Donahoe, Vice Pres.

Dr. R. H. McBride, Secy.

Dr. Frank Winkler, Treas.

BOARD OF EDITORS

Montana State Medical Assn.

Dr. M. A. Shillington, Pres.

Dr. L. W. Allard, Pres.-Elect
Dr. H. T. Caraway, Secy.-T reas.
Northwestern Pediatric Society
Dr. G. B. Logan, Pres.

Dr. Geo. Kimmel, Vice Pres.

Dr. Northrop Beach, Secy.-T reas.
Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.

Dr. R. C. Webb, Secy. -Treas.
American Student Health Assn.

Dr. Ralph I. Canuteson, Pres.

Dr. Laurence Chenoweth, Vice Pres.
Dr. G. T. Blydenburgh, Secy. -Treas.

Dr. J . O. Arnson
Dr. A. B. Baker
Dr. D. S. Baughman
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W. A. Fansler

Dr. J. A. Myers, Chairman

Dr. A. R. Foss
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. J. Mabee

Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C H. Nelson
Dr. N. J . Nessa
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. C. E. Sherwood

Dr. M. A. Shillington
Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. S. E. Sweitzer

Dr. W. H. Thompson
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin,
Secretary

LANCET PUBLISHING CO., Publishers, 84 South Tenth St., Minneapolis 2, Minnesota

Minneapolis, Minnesota, December, 1946

AN INCIDENT IN SURGERY
FIFTY-FIVE YEARS AGO

It is well now and then to be reminded of the ad-
vances in surgery by those of us who have been eye-
witnesses of its phenomenal progress. In this particular
case we look back to sharpen the contrast between the
appendectomy of today as compared to one performed
fifty-five years ago by Dr. Frank Epley in New Rich-
mond, Wisconsin. A few successful operations of this
type had been performed and reported but none in that
part of the state, therefore it was a matter of unusual
responsibility.

In preparation, three large emergency bags had been
packed and the steam sterilizer set out. Moist iodoform
and carbolated gauze and sponges in glass jars made up
the bulkiest parcels. Instruments were rarely boiled but
were submerged in trays of strong carbolic acid. Gowns,
hand towels, and gauze were sterilized for each opera-
tion. The gauze was used as an outermost dressing, cov-
ering the layers of absorbent cotton and gutta percha
beneath; it was not allowed to touch the wound unless

previously dipped in an antiseptic solution. Rubber gloves,
face masks, and head coverings were unknown.

With the arrival of Dr. Perry H. Millard as consult-
ant, everything was in readiness for the operation. The
room temperature was maintained at 100 degrees because
it was feared that inrushing air of a lower temperature
than that of the abdominal contents might produce shock
when the incision was made and the organs exposed.

The appendix had ruptured and there was a large peri-
toneal abscess. A weak, warm bichloride of mercury solu-
tion from a large fountain syringe was used to wash out
the pus at the time of the operation and at subsequent
dressings. Real sponges instead of gauze pledgets were
used to wipe away blood and pus. A fenestrated glass
tube with a collar near one end was used for drainage,
the collar preventing the tube from slipping into the
wound and becoming lost in the abdomen. Small round
openings in the tube were supposed to afford unobstruct-
ed drainage of pus and did facilitate the daily irrigation.

The patient recovered and Dr. Epley carried on his
work with renewed interest. A. E. H.

December, 1946

423

CHRISTMAS SEAL SALE

The Christmas Seal Sale in the cause of tuberculosis
control was instituted by individuals; first, Einer Holboell
of Denmark in 1904, then Emily P. Bissell of Wilming-
ton, Delaware, in 1907. From these beginnings the
Christmas Seal now plays a major role in tuberculosis
control. Emily Bissell’s sale in Delaware brought a re-
turn of $3,000. The possibility of this becoming a potent
fund-raising method attracted the attention of the Amer-
ican Red Cross, which launched a sale on a national basis
in 1908 with a reward of $135,000. In 1910 the Red
Cross and the National Tuberculosis Association entered
into a partnership whereby the former financed the ex-
pense of the sale and contributed its emblem, prestige
and name, while the latter did the organization work,
conducted the sale and determined the proper expendi-
ture of the funds. For ten years the Red Cross fostered
the fund-raising campaigns of the National Tuberculosis
Association. By 1920 the National Association had be-
come so strong that officials of the Red Cross were of the
opinion that special support was no longer necessary. For
the past twenty-six years the National Association has
conducted the seal sale alone.

Tuberculosis societies have been organized throughout
the country, until today there are 2,900 of them co-oper-
ating with the National Association. These organizations
participate in the Christmas Seal Sale. They all have
the same objective, namely, the eradication of tubercu-
losis, and they are operated under the world-wide symbol
of the tuberculosis movement, the red, double-barred
cross.

All Christmas seals for this nation are produced by the
National Association. The paper on which the seals are
printed is the largest single order for gummed paper in
the United States. Over two billion individual Christ-
mas seals are lithographed annually. This work is done
in the spring and summer and delivered by September
to the associations planning to sell them which, in turn,
place them in the twenty million envelopes to be mailed
to individuals and families the latter part of November.
Not all of the seals mailed bring a financial return; only
about 43 per cent of them are accepted and paid for by
recipients.

The Seal Sale reached its peak in 1945 with a gross
income of $15,638,755.37. Ninety-five per cent of the
annual income remains in the states from which it is
derived and enables state, county and city organizations
to conduct their year-round activities in the prevention
and control of tuberculosis. Five per cent is sent to the
National Association to aid in the solution of special
regional and national problems.

The Christmas Seal Sale also has an important educa-
tional value. The seals subtly and in the most cheerful
way possible promulgate the message of tuberculosis con-
trol. It has become as closely identified with the holidays
as Santa Claus himself. The educational value of the

seal has been such that there probably is no disease con-
cerning which the public is so well informed.

Courtesy and ethics have caused most other health and
philanthropic organizations to refrain from promoting
their work by the sale of seals. They have left the
Christmas Seal closely identified with tuberculosis in the
minds of the general public. This has been a fine display
of wisdom on the part of other organizations, inasmuch
as tuberculosis has been almost a universal scourge, so
much so that even at the beginning of this century few
families escaped it in some form of its development; also
because the National Tuberculosis Association and its
component societies have rendered a fine accounting of
their stewardship. This is manifested by the decline of
mortality from 200 deaths annually per 100,000 persons
living at the opening of the century, to approximately
40 per 100,000 at present. The morbidity has decreased
proportionately, and the incidence of tuberculous infec-
tion is spectacularly reduced. Indeed, the disease has
been completely eradicated at the grade school age level
in sizeable areas of this country.

Much remains to be done. Tuberculosis is still the
seventh cause of death among the diseases of this nation.
Therefore, other health agencies should continue to ab-
stain from the use of seal sales in fund-raising cam-
paigns, and all persons should participate heartily in the
promotion of the tuberculosis Christmas Seal Sale in
order that the excellent record of the past may be con-
tinued or even improved. J. A. M.

424

Views Items

NEWS FROM SOUTH DAKOTA

Dr. W. H. Cubbins, a member of the board of gov-
ernors of the American College of Surgeons, has been
added to the staff of the newly-expanded four-year med-
ical school at the South Dakota State University as pro-
fessor of surgery, Dean Donald Slaughter announced.
Dr. Cubbins is one of the founders of the Journal of
Surgery, Gynecology, and Obstetrics, and of the Ameri-
can College of Surgeons.

Dr. Walter L. Hard of East Lansing, Michigan, has
recently been appointed chairman and professor of the
department of anatomy of the South Dakota State Uni-
versity four-year medical school. Dr. Duke received a
teaching fellowship at Duke University in zoology and
was graduated from that institution in 1937 with a
Ph.D. degree.

NEWS FROM NORTH DAKOTA

Dr. A. H. Reiswig of Wahpeton, South Dakota, re-
ceived the degree of Associate in the International Col-
lege of Surgeons at Detroit, Michigan, in October. The
honor was conferred during a three-day meeting of the
group.

Sponsored by the state health planning committee, a
meeting of representatives of groups interested in health
problems was held in Bismarck November 19 for the dis-
cussion of the health, medical, and hospital situation in
the state. Participating in the discussions were Dr. W.
G. Wright of Williston, chairman of the economics com-
mittee of the state medical association, Dr. Robert Ray
of Garrison, Dr. William M. Smith of Bismarck, acting
state health officer, Dr. A. E. Spear, Dickinson, presi-
dent of the state medical association, Dr. A. C. Bach-
meyer, director of study of the commission on hospital
care and director of the University of Chicago clinics,
and Dr. J. F. Hanna of Fargo.

NEWS FROM MINNESOTA

Mrs. R. E. Scammon of the board of public welfare.
Dr. E. J. Huenekens of Hennepin County Medical So-
ciety, and Dr. Frank J. Hill, city health commissioner,
have been named by Mayor Hubert Humphrey to work
with the public health division in sponsoring a city-wide
chest X-ray survey.

Dr. George C. Kimmel of Red Wing, Minnesota, was
elected president of the Northwest Pediatric Society at
its annual meeting held recently at Bayport. The North-
west society consists of North and South Dakota, Mon-
tana, Wisconsin and Minnesota.

Dr. Clifford O. Ericks has resigned as assistant super-
intendent of the Rochester state hospital to enter private
psychiatric practice with Dr. Harold Noran of Min-
neapolis.

Officials of the medical associations of Minnesota,
Iowa, Nebraska, Wisconsin, North and South Dakota

The Journal-Lancet

met in St. Paul on November 10 for the annual North
Central medical conference.

The North Central section of the American Urologi-
cal Association met recently in Rochester for a three-day
session. Dr. William J. Baker of Chicago was named
president for the coming year, to succeed Dr. Walter M.
Kearns of Milwaukee. Dr. Robert S. Breakey of Lan-
sing, Michigan, was named president-elect, and Dr. Rus-
sell D. Herrold of Chicago was re-elected secretary-
treasurer.

Dr. D. J. Halpern, Brewster, is the new president of
the Southwestern Minnesota Medical Society, elected at
the annual meeting of the group held here recently. Dr.
F. L. Schade of Worthington was chosen president-elect,
Dr. John Lohmann, Pipestone, vice president, and Dr.
B. O. Mork, Jr., Worthington, was re-elected secretary-
treasurer.

Dr. Robert Davies, associate medical director of No-
peming sanatorium, near Duluth, was chosen from a
field of twenty applicants to be medical director of
Morningside tuberculosis hospital at Seattle, Washing-
ton, where he will assume his new job about January 1.

^beatlu

Dr. Francis Peake, 75, who had practiced in James-
town, North Dakota, since 1908, died October 26.

Dr. William E. Patterson, 71, Minneapolis physician
for the past 29 years, died October 30.

Dr. Harry T. Frost, 53, of Wadena, Minnesota, died
at Detroit Lakes on October 27.

Dr. Mathias Sundt, 63, who was a member of the staff
of Fairview hospital, Minneapolis, died October 21.

Dr. Thomas L. DePuy, 59, of Jamestown, North Da-
kota, died October 24.

Dr. Nathan J. Braverman, 44, died at Duluth, Min-
nesota, on October 14.

Dr. Henry Foshager, 55, Clara City, Minnesota, died
October 19.

Dr. J. G. Chichester, 70, physician and surgeon in
Redfieid, South Dakota, since 1904, died September 5.

Dr. Harold C. Joesting, 42, former Butte, Montana,
physician and surgeon, died in Los Angeles, California,
September 18. He was one of the founders and the first
president of the Butte clinic.

Dr. Benjamin Shalett, 58, New York physician, was
born in Minneapolis, where he practiced for a number
of years. He died in New York September 17.

Dr. C. M. Roan, 68, Minneapolis physician, died
September 11.

Dr. Frank M. Loring, 85, of Howard, South Dakota,
pioneer physician and surgeon in Sanborn and Miner
counties, died September 11.

Dr. Henry J. Rock, 82, former Sioux Falls, South
Dakota physician, died in Wilmington, Delaware, Sep-
tember 9.

®f|C

JournahlGantet

INDEX TO

VOLUME LXVI

New Series

January 1946 - December 1946

The Official Journal of the
North Dakota State Medical Association
South Dakota State Medical Association
Montana State Medical Association
Sioux Valley Medical Association
Great Northern Railway Surgeons’ Association
Minneapolis Academy of Medicine
North Dakota Society of Obstetrics and Gynecology
South Dakota Public Health Association
American Student Health Association
Northwestern Pediatric Society

Lancet Publishing Company, Publishers
Minneapolis, Minnesota

1946

The Journal-Lancet

INDEX OF AUTHORS

Abbott, Kenneth H. See Woltman, Henry W., co-author
Adams, Forrest H. See Platou, Erling S., co-author
Adson, Alfred W. See Woltman, Henry W., co-author
Alpers, Bernard J., The brain changes associated with electri-
cal shock treatment: a critical review, 363
Arey, Stuart Lane, Post-measles and post-mumps encepha-
litis, 188

— , Two cases of hemolytic anemia with leukemoid re-
action of the myeloid type, 166

Arrasmith, Winfred W., Massive hemorrhage from the upper
digestive tract, 209

, Cohen, Joseph T., and Litow, M. M., The use of

general anesthesia in the treatment of extensive caries in
problem children, 148

Koons, Melvin E., Free plasma service in North Dakota, 4

, A report on the use of two thousand units of dried

plasma under a state-wide health department program, 222
La Vake, R. T., Serology and obstetrics, 1
, Serology and obstetrics, II, 244

Leiter, Herbert C., Some common skin diseases and their
treatment

Lippman, Hyman S., Direct psychiatric treatment of the child,
161

Baird, Joe W., Oxygen therapy, 193

Baker, A. B., and Daly, David, Endogenous toxic encephalitis,

381

Litow, M. M. See Knight, Ralph, co-author
Logan, George B., and Keith, Haddow M., The successful
treatment of subacute bacterial endocarditis of children with
penicillin, 145

Blegen, H. M., and Boyer, Esther, Perforation of chole-
dochus cyst with biliary peritonitis, 177
Bond, Douglas D., The psychiatrist looks at family life, 377
Boyer, Esther L. See Blegen, H. M., joint author
Briggs, John Francis, and Geer, Everett K., The out-patient
chest clinic, 114

Burke, Edmund C., and Platou, Erling S., Biliary obstruc-
tion in the newborn with recovery, 232
Butler, John M., Short leg backache, 10

Canuteson, Ralph I., Looking ahead in health service, 227
Clagett, O. Theron, Surgery of the stomach, 403
Clayman, S. G., Report of an unusual case of mediastinal
tumor, 184

Cohen, Abraham. See Goldman, Joel, joint author
Cohen, Joseph T. See Knight, Ralph, co-author
Collins, L. L., Tuberculosis control depends upon the practic-
ing physician, 103

Daly, David. See Baker, A. B., joint author
Diehl, Harold S., Remarks for Variety Club heart hospital
dinner, 419

Drew, Harry O., Diet and the liver, 319
Dyson, Ralph E., Mesenteric cyst, 155

Egan, Richard L., Thiouracil in the management of hyperthy-
roidism, 326

Emerson, Kendall, Tuberculosis and war, (Foreword), 95
Evans, Charles A., The immunology of poliomyelitis, 328

Geer, Everett K. See Briggs, John F., joint author
Gibbs, R. W. See Platou, Erling S., co-author
Goldman, Joel, and Cohen, Abraham, The use of physostig-
mine and neostigmine therapy in neuromuscular dysfunction
caused by trauma (with special reference to the sequelae of
war wounds), 415

Gowan, L. R., Psychiatric care in general hospitals, 389
Grinker, Roy R., A note on the development of speech pat-
terns, 370

Grunfel, Judith, Future prospects for physicians, 229

Healy, James C., Hypochromic anemia: treatment with molyb-
denum-iron complex, 218

Hudson, Ellis Herndon, Filariasis and malaria on the campus,
191

Jacobs, Sydney, The chronic cough, (Reprint) , 74

, The tuberculin test, (Reprint), 72

Keith, Haddow M. See Logan, George B., joint author
Knight, Ralph T., Anesthesia in general practice, 323

Mantz, Herbert L., Histoplasmin skin sensitivity and pulmo-
nary calcifications, 100

Mauss, I. H., A comparison of the response of gonorrhea to
sulfathiazole and penicillin, 65

Morris, Sarah I., The hazard of tuberculosis during medical
training, 109

Myers, J. Arthur, Chester Arthur Stewart, a personal appre-
ciation, 132

, John Charnley McKinley: A personal appreciation,

351

, Tuberculosis control in colleges and universities, 409

Novak, Julius B., Who should have the tuberculin test?, 116

Odegard, John K. See Scherer, Roland G., joint author
Olson, W. E., Electroshock convulsion therapy, 68

Pelner, Louis, Aids in the diagnosis of intestinal obstruction,
81

, The sprue syndrome, 79

Peterson, Willard E., Report of a one-year survey of a diag-
nostic tuberculosis service in a general hospital, 118
Platou, Erling S., Gibbs, R. W., and Adams, Forrest H.,
Treatment of chronic influenzal meningitis: heparin as an
adjuvant, 157

, See Burke, Edmund C., joint author

, See Tudor, Richard B., joint author

Pletsch, Donald J., Anopheline mosquitoes in Montana, 289
Pray, L. G., Mesenteric cysts causing intestinal obstruction in
infancy, 152

Proffitt, William E., and Wyatt, Oswald S., Giant-cell
tumor of bone in a four-month-old infant, 163

Quello, R. O., Plasma proteins in surgery: a review of the
literature, 399

Reese, Hans H., What do we know of multiple sclerosis?, 359

Sander, O. A., The relationship of tuberculosis and silicosis, 96
Sarff, Oliver Elton, Treatment of prostatism, The, 215
Schatz, Albert I. See Waksman, Selman, co-author
Schemm, F. R., High fluid intake regime in the management
of edema, 50

Scherer, Roland G., and Odegard, John K., Spontaneous
rupture of a hydronephrotic kidney, 241
Schiele, Burtrum C., Huntington’s chorea in relation to the
heredity of personality disorders, 393
Simons, Edwin J., Facts and inferences of Minnesota sana-
torium admittances, 105

Skogland, John E., Occlusion of arteries supplying the brain-
stem and cerebellum, 385

December, 1946

427

Spink, Wesley W., Sulfonamides and antibiotics in the preven-
tion and treatment of infectious diseases, 277
Strecker, Edward A., War psychiatry and its influence upon
postwar psychiatry and upon civilization, 357

Tudor, Richard B„ and Platou, Erling S., The celiac syn-
drome, 142

Van Demark, Robert E., The treatment of trimalleolar frac-
tures of the ankle, 196

Waksman, Selman, and Schatz, Albert I., The present
status of streptomycin therapy (Reprint) , 77
Wangensteen, Owen H., The graduate student and research,
284

, The ulcer problem, 31

Weech, A. A., The challenge of postwar pediatrics, 138
Welty, Dalton M., Chronic unstable colon, 55
Woltman, Henry W., Adson, Alfred W., and Abbott,
Kenneth H., Neuritis ossificans with osteogenic sarcoma
in brachial plexus following trauma; report of case, 372
Wyatt, Oswald S. See Proffitt, William E., joint author

INDEX OF ARTICLES

Aids in the diagnosis of intestinal obstruction, Louis Pelner, 81
A.M.A. house of delegates meeting (editorial), 20
American Student Health Association:

Fifteenth annual report of Tuberculosis Committee, 171
News-Letter and Digest of Medical News, 72, 94, 195,
236, 329, 420

Anesthesia in general practice, Ralph T. Knight, 323
Anopheline mosquitoes in Montana, Donald J. Pletsch, 289
As the life span lengthens (editorial), 271

Biliary obstruction in the newborn with recovery, Edmund C.

Burke and Erling S. Platou, 232
Brain changes associated with electrical shock treatment: a crit-
ical review, Bernard J. Alpers, 363

Celiac syndrome, The, Richard B. Tudor and Erling S. Pla-
tou, 142

Challenge of postwar pediatrics, The, A. A. Weech, 138
Christmas seal sale (editorial) , 423
Chronic cough, The, Sydney Jacobs, (Reprint), 74
Chronic unstable colon, Dalton M. Welty, 55
Comparison of the response of gonorrhea to sulfathiazole and
penicillin, I. H. Mauss, 65
Co-operative health unit organized (editorial), 314

Diet and the liver, Harry O. Drew, 319

Direct psychiatric treatment of the child, Hyman S. Lippman,
161

Electroshock convulsion therapy, W. E. Olson, 68
Endogenous toxic encephalitis, A. B. Baker and David Daly,
381

Facts and inference of Minnesota sanatorium admittances, Ed-
win J. Simons, 105

Filariasis and malaria on the campus, Ellis Herndon Hudson,
191

Free plasma service in North Dakota, Melvin E. Koons, 4
"Functional heart murmurs” unsatisfactory term (editorial) ,
348

Future of psychiatry, The (editorial), 398
Future prospects for physicians, Judith Grunfel, 229

Giant-cell tumor of bone in a four-month-old infant, William
E. Proffitt and Oswald S. Wyatt, 163

Graduate student and research, Owen H. Wangensteen, 284

Hazard of tuberculosis during medical training, Sarah I. Mor-
ris, 109

High fluid intake regime in the management of edema, F. R.
Schemm, 50

Histoplasmin skin sensitivity and pulmonary calcifications, Her-
bert L. Mantz, 100

Huntington’s chorea in relation to the heredity of personality
disorders, Burtrum C. Schiele, 393
Hypochromic anemia: treatment with molybdenum-iron com-
plex, James C. Healy, 218

Immunology of poliomyelitis, Charles A. Evans, 328

Incident in surgery fifty-five years ago, An, (editorial), 422
Looking ahead in health service, Ralph I. Canuteson, 227

Massive hemorrhage from the upper digestive tract, Winfred
W. Arrasmith, 209

McKinley, John Charnley: A personal appreciation, J. Arthur
Myers, 351

Measuring the community for a hospital, (condensation) 24
Medical continuation courses at University of Minnesota, winter
and spring, 1946, 21

Medical conventions again (editorial), 199
Medical outlook for the new year (editorial), 19
Mesenteric cyst: report of a case, Ralph E. Dyson, 155
Mesenteric cysts causing intestinal obstruction in infancy, L. G.
Pray, 152

Minnesota State Board of Medical Examiners, List of physi-
cians licensed by, November 9, 1945, 29
Montana State Medical Association: roster, 343; transactions,
331; women’s auxiliary, 347

Nation’s birth and maternal record improves, (editorial) , 58
Neuritis ossificans with osteogenic sarcoma in brachial plexus
following trauma: report of a case, Henry W. Woltman,
Alfred W. Adson, and Kenneth H. Abbott, 372
Neurology:

Brain changes associated with electrical shock treatment:
a critical review, Bernard Alpers, 363

Endogenous toxic encephalitis, A. B. Baker and David Daly,
381

Neuritis ossificans with osteogenic sarcoma in brachial plexus
following trauma; report of a case, Henry W. Woltman,
Alfred W. Adson and Kenneth FI. Abbott, 372

Occlusion of arteties supplying the brain-stem and cerebel-
lum, John E. Skogland, 385

What do we know of multiple sclerosis? Hans H. Reese,
359

North Central states socio-medic problems (editorial) , 397
North Dakota State Medical Association: House of Delegates,
transactions, 290; roster, 309

Note on the development of speech patterns, A., Roy R.
Grinker, 370

Occlusion of arteries supplying the brain-stem and cerebellum,
John E. Skogland, 385

Out-patient chest clinic, The, John Francis Briggs and Everett
K. Geer, 114

Oxygen therapy, Joe W. Baird, 193

Passing of the family doctor, The (editorial), 350
Pediatrics:

Biliary obstruction in the newborn with recovery, Edmund
C. Burke and Erling S. Platou, 142

428

The Journal-Lancet

Celiac syndrome, The, Richard B. Tudor and Erling S.
Platou, 142

Challenge of postwar pediatrics, The, A. A. Weech, 138
Direct psychiatric treatment of the child, Hyman S. Lipp-
man, 161

Giant-cell tumor of bone in a four-month-old infant, Wil-
liam E. Proffitt and Oswald S. Wyatt, 163
Mesenteric cyst: report of a case, Ralph E. Dyson, 155
Mesenteric cysts causing intestinal obstruction in infancy,

L. G. Pray, 152

Successful treatment of subacute bacterial endocarditis of
children with penicillin, George B. Logan and Haddow

M. Keith, 145

Treatment of chronic influenzal meningitis: heparin as an
adjuvant, E. S. Platou R. W. Gibbs, and Forrest H.
Adams, 157

Two cases of hemolytic anemia with leukemoid reaction of
the myeloid type, S. L. Arey, 166
Use of general anesthesia in the treatment of extensive caries
in problem children, Ralph T. Knight, Joseph T. Cohen,
and M. M. Litow, 148

Perforation of choledochus cyst with biliary peritonitis, H. M.

Blegen and Esther L. Boyer, 177
Physicians licensed by the Minnesota State Board of Medical
Examiners, List of November 9, 1945, 29
Physicians too many or too few, (editorial) , 57
Plasma proteins in surgery: a review of the literature, R. O.
Quello, 399

Post-measles and post-mumps encephalitis, Stuart Lane Arey,
188

Present status of streptomycin therapy, by Selman A. Waks-
man and Albert I. Schatz (reprint), 77
Psychiatric care in general hospitals, L. R. Gowan, 389
Psychiatrist looks at family life, The, Douglas D. Bond, 377
Psychiatry:

Electroshock convulsion therapy, W. E. Olson, 68
Future of psychiatry, The, (editorial), 398
Huntington’s chorea in relation to the heredity of person-
ality disorders, Burtrum C. Schiele, 393
Note on the development of speech patterns, A,. Roy R.
Grinker, 370

Psychiatric care in general hospitals, L. R. Gowan, 389
Psychiatrist looks at family life, The, Douglas D. Bond, 377
Psychotherapy strides forward (editorial), 83
War psychiatry and its influence upon postwar psychiatry
and upon civilization, Edward A. Strecker, 357
Psychotherapy strides forward (editorial) , 83

Relationship of tuberculosis and silicosis, O, A. Sander, 96
Report of a one-year survey of a diagnostic tubercuolsis service
in a general hospital, Willard E. Peterson, 118
Report of an unusual case of mediastinal tumor, S. G. Clayman,
184

Report on the use of two thousand units of dried plasma under
a state-wide health department program, Melvin E. Koons,

222

Serology and obstetrics, R. T. La Vake, 1
Serology and obstetrics (II), R. T. La Vake, 244
Short leg backache, John M. Butler, 10

Some common skin diseases and their treatment, Herbert C.
Leiter, 12

South Dakota forges ahead (editorial), 239
South Dakota State Medical Association: roster, 264; transac-
tions, 247; women’s auxiliary, 268
Spontaneous rupture of a hydronephrotic kidney, Roland G.

Scherer and John K, Odegard, 241
Sprue syndrome, The, Louis Pelner, 79

Stewart, Chester Arthur: A personal appreciation, J. Arthur
Myers, 132

Stewart, Dr. Chester Arthur, at Louisiana, 1941-46 (editorial),
169

Strenuous holidays (editorial) 237

Streptomycin in treatment of tularemia (editorial), 271
Successful treatment of subacute bacterial endocarditis of chil-
dren with penicillin, George B. Logan and Haddow M. Keith,
145

Sulfonamides and antibiotics in the prevention and treatment
of infectious diseases, Wesley W. Spink, 277
Surgery of the stomach, O. Theron Clagett, 403

Thiouracil in the management of hyperthyroidism, Richard L.
Egan, 326

Transmission of poliomyelitis, The (editorial), 315
Treatment of chronic influenzal meningitis: heparin as an ad-
juvant, E. S. Platou, R. W. Gibbs, and Forrest H. Adams,
157

Treatment of prostatism, The, Oliver Elton Sarff, 215
Treatment of trimalleolar fractures of the ankle, Robert E. Van
Demark, 196

Tuberculin test, The, Sydney Jacobs, (reprint), 72
Tuberculosis:

Chirstmas seal sale (editorial), 423
Chronic cough, The, Sydney Jacobs, 74
Facts and inferences of Minnesota sanatorium admittances,
Edwin J. Simons, 105

Hazard of tuberculosis during medical training, Sarah I.
Morris, 109

Out-patient chest clinic, The, John Francis Briggs and Ev-
erett K. Geer, 114

Relationship of tuberculosis and silicosis, O. A. Sander, 96
Report of a one-year survey of a diagnostic tuberculosis serv-
ice in a general hospital, Willard E. Peterson, 118
Tuberculin test, The, Sydney Jacobs, 72
Tuberculosis among college students, 15th annual report of
the Tuberculosis Committee, American Student Health
Association, 171

Tuberculosis and war, Kendall Emerson, 95
Tuberculosis control depends upon the practicing physician,
L. L. Collins, 103

Tuberculosis control in colleges and universities, J. Arthur
Myers, 409

Tuberculosis is contagious (editorial), 121
Tuberculosis prevalence revealed through autopsies (edi-
torial), 122

Vaccination and tuberculosis (editorial), 238
Who should have the tuberculin test? Julius B. Novak, 116
Tuberculosis among college students, 15th annual report of the
Tuberculosis Committee, American Student Health Associa-
tion, 17 1

Tubercuolsis and war, Kendall Emerson, (Foreword), 95
Tuberculosis control depends upon the practicing physician,
L. L. Collins, 103

Tuberculosis control in colleges and universities, J. Arthur
Myers, 409

Tuberculosis is contagious (editorial), 121

Tuberculosis prevalence revealed through autopsies (editorial),

122

Two cases of hemolytic anemia with leukemoid reaction of the
myeloid type, S. L. Arey, 166

Ulcer Problem, The, Owen H. Wangensteen, 31
Ues of general anesthesia in the treatment of extensive caries
in problem children, Ralph T. Knight, Joseph T. Cohen,
and M. M. Litow, 148

Use of physostigmine and neostigmine therapy in neuromuscular
dysfunction caused by trauma (with special reference to the

December, 1946

429

sequelae of war wounds) , Joel Goldman, Abraham Cohen,
415

Vaccination and tuberculosis (editorial), 238
Variety Club heart hospital dinner, remarks for, H. S. Diehl,
419

War psychiatry and its influence upon postwar psychiatry and
upon civilization, Edward A. Strecker, 357
What do we know of multiple sclerosis? Hans H. Reese, 359
Who should have the tuberculin test? Julius B. Novak, 116

EDITORIALS

A.M.A. house of delegates meeting, 20

As the life span lengthens, 271

Christmas seal sale, 423

Co-operative health unit organized, 314

Dr. Chester Arthur Stewart at Louisiana, 1941-1946, 169

"Functional heart murmurs” unsatisfactory term, 348

Future of psychiatry, The, 398

Incident in surgery fifty-five years ago. An, 422

Medical conventions again, 199

Medical outlook for the new year, 19

Nation’s birth and maternal record improves, 58

North Central states socio-medic problems, 397

Passing of the family doctor, The, 350

Physicians too many or too few, 57

Psychotherapy strides forward, 83

South Dakota forges ahead, 239

Strenuous holidays, 237

Streptomycin in treatment of tularemia, 271

Transmission of poliomyelitis, The, 315

Tuberculosis is contagious, 121

Tuberculosis prevalence revealed through autopsies, 122
Vaccination and tuberculosis, 238
Wash less after sun baths, 270

BOOK REVIEWS

Ambulatory Proctology, by Alfred J. Cantor, 236
Arthropies, The: A Handbook of Roentgen Diagnosis, by Al-
fred A. de Lorimier, 59

Bibliography of Infantile Paralysis, 1789-1944, with Selected
Abstracts and Annotations, edited by Morris Fishbein, 198
Blind Hog's Acorns, A, by Carey P. McCord, 330
Brazil: Orchid of the Tropics, by Mulford B. Foster and Ra-
cine S. Foster, 87

Classic Descriptions of Disease, by Ralph H. Major, 86
Clinical Electrocardiography, by David Scherf and Linn J.
Boyd, 137

Corky the Killer, a Story of Syphilis, by Harry A. Wilmer, 330
Curare-Intocostrin, prepared and edited by E. R. Squibb &
Sons, 330

Dietary of Health and Disease, The, by Gertrude I. Thomas,
87

Dysentery, Colitis and Enteritis, by Joseph Felsen, 86

Electrocardiography in Practice, by Ashton Graybird and Paul
D. White, second edition, 313

Essentials of Allergy, by Leo H. Criep, 18

Facial Prosthesis, by Arthur H. Bulbulian, 59

General and Plastic Surgery, with Emphasis on War Injuries,
by J. Eastman Sheehan, 18

Gastro-Enterology. Vol. Ill: The Liver, Biliary Tract and Pan-
creas, and Secondary Gastro-Intestinal Disorders, by Henry
L. Bockus, 137

Herbal of Rufinus, The, edited by Lynn Thorndyke, 18
Home Study Course in Social Hygiene Guidance, by Roy E.

Dickerson and Paul Popence, 246
Hypoanalysis, by Lewis R. Wolberg, 86

Intravenous Anesthesia, by R. Charles Adams, 165

Manual of Tubercuolsis, Clinical and Administrative, by E.
Ashworth Underwood, 330

Medical Clinics of North America, Mayo Clinic Number, 246

Men Without Guns, by DeWitt Mackenzie, 59

Mirror for Cure-Takers, A, edited by Harold Holand, 124

Oral Medicine, by Lester W. Burket, 330

Physical Chemistry of Cells and Tissues, by Rudolph Hober, 18
Pictorial Handbook of Fracture Treatment, by E. L. Compere
and S. W. Banks, 87

Pneumoperitoneum Treatment, by Andrew L. Banyai, 313
Prescribing Occupational Therapy, by William Rush Dunton,
Jr-, 59

Psychotherapy in General Medicine, by Geddes Smith, 392
Physiology of the Newborn Infant, The, by Clement A. Smith,
165

Rehabilitation at Lake Tomahawk State Camp, by Harold Ho-
land, 137

Science and Scientists in the Netherlands Indies, edited by
Pieter Honig and Frans Verdoorn, 165
Sex Endocrinology: A Handbook for the Medical and Allied
Professions, Schering Corporation, 18
Skin Diseases in Children, by George M. Mackee and Anthony
C. Cipollaro, 165

Structure and Function of the Human Body, by Ralph N. Bail-
lif and Donald L. Kimmel, 60

Suggested School Health Policies: A Charter for School

Health, National Conference for Cooperation in Health
Education, 86

Surgical Clinics of North America, Mayo Clinic Number, 246
Surgical Treatment of the Nervous System, by F. W. Bancroft
and C. Pilcher, 392

Surgical Treatment of the Motor-Skeletal System, edited by
Frederic W. Bancroft and Clay Ray Murray, 198

Toward Mental Health, by George Thorman, 392
Trauma in Internal Diseases, with Consideration of Experimen-
tal Pathology and Medicolegal Aspects, by Rudolf A. Stern.
86

Women in Industry: Their Health and Efficiency, by Anna M.
Baetjer, 330

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